Emilee is going to leadership clinical today

Emilee is going to leadership clinical today to follow a team leader to understand prioritization of patient care needs. She meets the team leader in the morning, and they go over the assignment for today. There is experienced RN, LPN, and unlicensed assistive personnel on the team for six adult medical patients. The night shift nurse gives a report on the following six patients: 1. A 52-year-old woman with acute glomerulonephritis 2. A 68-year-old male with hepatitis and liver cirrhosis and esophageal varices 3. A 24-year-old hemophiliac 4. A 60-year-old man with a deep vein thrombosis (DVT) in the left leg 5. A 44-year-old woman who had a left mastectomy yesterday 6. A 72-year-old woman with acute diverticulitis Exercise 10-1: Multiple-choice After hearing the morning report, who should Emilee assess first? A. The woman with brown-colored urine who has glomerulonephritis B. The man with liver cirrhosis who’s complaining of abdominal discomfort C. The man with hemophilia who has bleeding into his right elbow joint D. The 44-year-old woman with 30 mL of drainage in her Jackson Pratt who had a left mastectomy yesterday Next, Emilee and her preceptor check patient laboratory reports. Exercise 10-2: Multiple-choice Which report needs to be called to the primary care provider (PCP) first? A. The white blood cell count, which is 7.8 mm3, on the woman who had the mastectomy B. The man with cirrhosis who has a cholesterol of 240 mg/dL C. The 60-year-old man with a DVT with an international normalized ratio (INR) of 2.5 D. The woman with glomerulonephritis with a calcium of 7.9 mg/dL After checking labs, Emilee checks PCP orders. Exercise 10-3: Multiple-choice Which order should the nurse for the patient with esophageal varices? A. Insert a nasogastric tube B. Start intravenous D5W at 200 mL/hr. C. Nothing by mouth (NPO) D. Keep head of bed (HOB) in a 30-degree angle Emilee asks the preceptor how she will know which patient is the priority. The preceptor tells her there are some guiding principles to go on, but you can never say “always” in nursing because it is a human service. When dealing with humans there are always multiple variables. It takes critical thinking to look at the variables and make a clinical decision. One guideline is Maslow’s hierarchy of needs. Exercise 10-4: Ordering Order the following Maslow hierarchy of needs from 1 to 5: ______ Safety ______ Esteem ______ Physiological ______ Self-actualization ______ Love and belongingness Another guideline that Emilee’s preceptor tells her about is physiological before psychological, and the preceptor tells Emilee of a situation that she has experienced on a surgical unit. Exercise 10-5: Multiple-choice On a surgical unit, which patient should the nurse assess first? A. A patient with a laparoscopic tubal ligation who is reporting some gastric distension B. A patient with a cholecystectomy who is 2 hours postoperative and has not voided C. A patient scheduled for a mastectomy who is crying D. A patient who has a microscopic proctectomy and is ready to go home Emilee’s preceptor tells her it is helpful to think of a decision in these terms: 1. Is it an emergency and if it is, did you summon help? 2. Is there a safety issue that can be averted? 3. Are Maslow’s hierarchy of needs met? 4. Are the physiological issues more important here than the psychological issues? 5. Most importantly: Do I have enough information, or do I need to further assess? The preceptor provides Emilee with five clinical situation questions that have come up in the preceptor’s past OB experience. Exercise 10-6- Multiple Choice While working on a postpartum unit the preceptor was faced with deciding which patient to see first. The preceptor asks Emilee whom she would see: A patient who delivered 3 hours ago and had not voided yet. A patient who is crying because she has sore nipples from breastfeeding. A patient who has soaked a peri-pad in 3 hours. A patient who is complaining of severe vaginal discomfort after a difficult vaginal delivery. The preceptor now gives Emilee a newborn nurse scenario. Exercise 10-7 Multiple Choice Which infant would the nurse assess first? A 2-day old who is visibly jaundiced A 2-day old who has voided twice in 12 hours A 1 day-old with a resting heart rate of 200 A 1-day old who will not breastfeed Exercise 10-8 Multiple Choice The triage nursery nurse receives the following phone calls. Which parent should the nurse call back first? The parent who tells the nurse her 5-month-old cried all night and pulled on her ear. The parent who states her 2-month-old baby has not has a bowel movement in 24 hours. The parent who reports that her 6-week-old baby is breastfeeding all the time. The parent who states her 6-week-old vomits after each feeding and takes long naps. Exercise 10-9 Multiple Choice : While working in the antepartum clinic, the nurse should assess which patient first? The women who is 14 weeks gestation with cheesy vaginal discharge who is uncomfortable from itching and irritation. The woman who is 28 weeks’ gestation with a 9-pound weight gain in 1 week. The woman who is 40 weeks’ gestation who is complaining of urinary incontinence. The woman who is 36 weeks’ gestation with a WBC count of 9.6. Exercise 10-10: Multiple Choice Which patient should the most experienced nurse see first? A 24-year-old hemophiliac who is waiting for discharge instructions. A 60-year-old man with a DVT in the left leg who is complaining of shortness of breath. A 44-year-old woman who had a left mastectomy yesterday who has a hematocrit postoperative of 30.2. A 72-year-old woman with acute diverticulitis who is complaining of bloating and gas. Exercise 10-11 Multiple Choice : Later that day a bed opened up in the intensive care unit. Which patient should be transferred to the ICU? A 68-year-old male with hepatitis, liver cirrhosis and esophageal varices and who is coughing up blood. A 24-year-opld hemophiliac who is resting comfortably after ice is applied to his elbow. A 44-year-old woman who had a left mastectomy yesterday who has spiked a temperature of 102.8F A 72-year-old woman with acute diverticulitis who has not had a bowel movement in 24 hours. Emilee agrees that prioritizing is difficult, and it takes her time to think through each patient’s needs and use her decision tree to see if she has enough information to intervene or if further assessment is warranted. Her preceptor does tell her that with experience and practice it gets easier, but that even after 20 years of experience, she needs to stop and think about which patient condition warrants the first response.

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