Question

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? a. Patient in pain b. Patient newly admitted c. Patient who returned from surgery d. Patient requesting assistance with meal tray

Short answer

c. Patient who returned from surgery

Step-by-step solution

Identify Critical Needs

Review all the patients' health conditions and needs to determine if there are any immediate life-threatening issues that need to be addressed.

Apply the ABCs of Priority Setting

Remember the ABCs of priority setting in healthcare, which stands for Airway, Breathing, and Circulation. Assess which patient's condition most closely involves these critical aspects.

Determine the Most Unstable Patient

The patient who has just returned from surgery has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. This indicates that this patient might be the most unstable and at the highest risk for complications, such as bleeding, respiratory distress, or infection.

Evaluate Other Patients' Needs

After ensuring there is no immediate life threat to the patient who has returned from surgery, quickly evaluate the needs of the other patients. While pain management, meal assistance, and settling in a newly admitted patient are important, they are not as time-sensitive as the postoperative patient's potential complications.

Make the Decision

Based on the given information and priority setting, the nurse should attend to the patient who just returned from surgery first. This patient's condition is likely to be the most complex and may require immediate intervention to prevent complications.

Key concepts

ABCs of Priority Setting

In nursing, effective priority setting is crucial, especially in situations where multiple patients require care simultaneously. The ABCs of Priority Setting stand for Airway, Breathing, and Circulation. This framework helps nurses quickly determine which patients need immediate attention and in what order to address their issues.

When a nurse comes across multiple scenarios, it’s essential to remember that maintaining a patient’s airway is the foremost priority because, without a clear airway, oxygen cannot reach the lungs. Breathing is the second priority; a patient needs to be able to breathe effectively to oxygenate their blood. Circulation is third; without proper blood flow, organs and tissues can not function properly, leading to serious health consequences.

Applying this model ensures that life-threatening conditions are treated first, helping to prevent complications and stabilize patients. Within this framework, a postoperative patient often needs immediate attention, especially if they're showing signs of respiratory distress, indicating potential airway or breathing issues that could quickly become critical.

Postoperative Patient Care

Postoperative care is a delicate period where close monitoring is essential. Complications can arise after surgery, including issues with the incision site, such as infection or hemorrhage, and systemic complications include deep vein thrombosis, pulmonary embolism, or respiratory problems.

Nursing care for postoperative patients includes several key priorities: monitoring vital signs to detect early signs of complication, managing pain to ensure comfort and facilitate healing, and providing wound care to prevent infection. Nurses must also monitor fluid and nutritional intake and output to ensure balanced hydration and nutrition, which are vital for recovery.

Furthermore, postoperative care entails assessing breathing and ensuring that the airway is clear. Since patients who have just undergone surgery might have a compromised airway or breathing pattern, it's particularly important to prioritize these patients, as done in the given exercise where the nurse rightly assesses the patient returned from surgery as the highest priority.

Nursing Decision-Making Process

The nursing decision-making process is a systematic approach that involves assessing, diagnosing, planning, implementing, and evaluating. Decision-making in nursing requires critical thinking and often must be done quickly, particularly in high-stakes or emergency situations.

Assessment involves gathering comprehensive information about the patient’s condition. Diagnosis comes from interpreting this data to identify the problem. Planning involves setting goals and determining the best course of action to address the patient’s needs. Implementation is carrying out the plan, and finally, evaluation is used to review the outcomes and determine if the plan was effective.

Within this systematic approach, prioritization is a key component. Nurses must efficiently triage their tasks and patients' needs, as seen in the exercise where the nurse must decide which patient requires immediate attention. By prioritizing the postoperative patient who may have urgent airway, breathing, or circulation needs, the nurse demonstrates sound decision-making, ensuring patients receive timely and appropriate care.