ATI: Priority Setting Frameworks

ATI: Priority Setting Frameworks Maslow's Hierarchy of Needs 1. Physiological 2. Safety & Security 3. Love & Belonging 4. Self-Esteem 5. Self-Actualization 1. Physiological Oxygentation Circulation Nutrition Elimination Fluid Balance Activity & Exercise Rest & Sleep 2. Safety & Security Living in safe environment Adequate income Shelter from environmental elements 3. Love & Belonging Love Affection Relationships Involvement with community and spiritual groups help to meet this need. 4. Self-Esteem Self respect Personal worth Social recognition 5. Self-Actualization Personal growth Fulfilling own potential Maslow's belief: very few individuals reach this level Client Care Focus (Maslow's) Higher levels may compete with lower levels (depends on client situation) Maslow's Hierarchy provides a framework Consider all client factors before determining order Nursing Process 1. Assessment First 2. Analysis 3. Planning 4. Implementation 5. Evaluation 1. Assessment LPN does data collection and lets the RN know pertinent information 2. Analysis RN only happens after nurse collects data second step of nursing process for RNs lays foundation for making decisions about client's plan of care takes priority over planning, implementation, and evaluation 3. Planning 3rd step RN 2nd step LPN establish outcomes and plan of care 4. Implementation 4th step RN 3rd step LPN interventions for health 5. Evaluation 5th step RN 4th step LPN in process or completed Using Maslow's Hierarchy as a priority-setting framework, which order should the following clients be cared for by the nurse? Client Care Focus (Nursing Process) tool to determine priority of nursing actions each step based on decisions from previous step most important: assessment (data collection) first evaluate client outcomes to determine effectiveness of care plan ABCDE A: Airway B: Breathing C: Circulation D: Disability E: Exposure A systematic method that can be utilized in any health care setting to evaluate and treat the client. 1. Airway highest priority action must be open and clear client might need: temporary oral or artificial airway (tracheostomy or endotracheal tude), supplemental oxygen 2.Breathing essential for oxygen exchange: respiratory rate with expected reference range, adequate ventilatory effort client might need: artificial ventilation, negative pressure gradient in pleural cavity, chest tube might re-establish negative pressure 3.Circulation heart rate and blood pressure within expected reference range necessary for adequate cardiac, cerebral, and peripheral perfusion client might need: chemical and/or physical cardiac support, resuscitation, supplemental fluids (to re-establish intravascular fluid volume and blood pressure) 4.Disability measuring disability involves determining a client's neurologic status. This includes the client's level of consciousness, response to verbal or painful stimulation, and level of orientation. 5. Exposure to complete this step, the nurse should uncover the client as needed to check the client from head to toe, while maintaining privacy and body temperature, and observing for any unexpected findings. A nurse is caring for a client who has asthma. Which of the following actions should the nurse identify as the priority? A Auscultate lung sounds B Check blood pressure C Compare bilateral radial pulses D Determine capillary refill Auscultate lung sounds (The nurse should monitor the client’s blood pressure, check bilateral radial pulses, and determine capillary refill to assess circulatory status; however, auscultating the lung sounds for a client who has asthma is the priority.) Safety & Risk Reduction assigns priority to the factor or situation posing the greatest: safety risk to the client, greatest risk to the client's physical or psychological well-being multiple risks may require another priority setting framework to identify risk posing greatest threat Sources of Safety Issues Client Nurse Provider Medical equipment and environment Home environment Community Risk Reduction Types of Risk: external- risks in client's environment; internal- lab values and VS outside their normal Use Maslow's Hierachy or ABC to determine greatest risk Risk posing immediate threat usually becomes highest priority Client Care Focus (Safety & Risk Reduction) Assess for external factors: complete risk assessment, integrate interventions, assistive devices Assess for internal factors: ABC combined with safety and risk reduction Least Restrictive/Least Invasive