Fundamentals of Nursing: Client Prioritization

Client prioritization is a nursing fundamental that is exercised in various hospital settings, especially after the client has gone through a traumatic situation or surgery. After going through the importance of prioritizing airway, breathing, and circulation, we’ll head on to the other concerns that nurses should focus on.

In this lecture, we’ll consider a client who has just gone out of the surgery room. Once you are done assessing for the client’s ABC, what should be the next area of importance? With cases like this, you always have to think about what’s going to kill the client the fastest. So, which among the following should be assessed after the ABCs?

  • Altered level of consciousness
  • Bleeding due to dehiscence and evisceration
  • Infection or sepsis
  • Pain
  • Elimination
  • Skin integrity

Maslow’s Hierarchy of Needs

Maslow’s Hierarchy of Needs theorized that if a client has established an appropriate airway, breathing, and circulation, the next aspects that should be given importance to should be safety and infection.

Elimination, nutrition, and pain come in after the ABCs and safety and infection.

Constipation is a common elimination issue that nurses encounter with post-operative clients. If a client is experiencing hard bowel movement, stool softeners or laxatives should be provided.

Pain will be given priority if the client has just had knee-replacement surgery or other orthopedic surgeries, for that matter. Clients who are complaining of pain will be assessed for:

  • Perfusion
  • Sensation
  • Motor movement
  • Pulses
  • Worsening, unrelieved pain

Compartmental Syndrome

Pain experienced by clients who underwent total knee replacement could indicate that he or she has compartmental syndrome.

Compartmental syndrome means that the client is suffering from internalized bleeding within the fascia portion of the muscles. As the fascia is filled up with blood, it produces a little sac that causes circulation to be cut off. One of the most significant indications of compartmental syndrome happening is that when the client grumbles about pain. And pain is the first indication that the client is in distress.

The Second Tier

As mentioned, the second tier will involve elimination, nutrition, pain, and skin integrity.

Pain moves on top of the second tier once it has something to do with chest pain – could be myocardial infarction or angina (stable or unstable). Because when this happens, it means that there is a lack of oxygen in the heart.

Skin integrity can lead to pressure ulcers which can cause infection. Nutrition is vital in this aspect because it can influence a client’s skin health, above everything else.

As mentioned, elimination is primarily concerned with either defecation or urination. Is there a small bowel obstruction that can cause proliferation and can lead to fatality?

The Third Tier

Client teaching and psychosocial aspects come in third when prioritizing. Client teaching is mostly concerned with imparting important information with clients regarding their health and lifestyle changes.

When it comes to discharge planning, client teaching always comes last. On the other hand, when prioritizing, saving lives is more important than educating clients.

For more nursing-related information that can help you pass major exams, especially the NCLEX™, visit our Simple Nursing website and check out our informative YouTube videos.

Perioperative Nursing: Post-Op Initial Assessment

In this part of our perioperative nursing lecture, we’ll be focusing on what’s going on inside a post-anesthesia care unit (PACU).

So, there are a couple of questions we will be answering as we go through this discussion, mainly:

  1. What happens in post-operative PACU?
  2. How long does a client stay inside the PACU?
  3. What are the major details that you have to be aware of inside the PACU?

Top Three Surgeries

Amongst tons of surgeries done inside an operating room, there are top three procedures that are commonly done, which are:

  1. Cardiac Surgery – coronary artery bypass
  2. Fixation – for broken bones
  3. Small bowel obstruction – “plumbing, cutting, and re-attaching” the small bowel

What Happens Inside the PACU?

For those who are unaware, when a client comes into the PACU, it means that surgery has been done and being the nurse in charge, there are a couple of things that you are required to do to ensure the safety and condition of your client.

So, the first thing that would happen inside the post-anesthesia care unit is that the anesthesiologist will inform you on the type of anesthesia that was given. Providing this kind of detail is essential to provide nurses with an idea regarding the status of their client, especially the drug which was used to suppress the central nervous system.

Whatever anesthesia is given, you can expect the following reactions from your client:

  • Slowed breathing
  • Slowed gastrointestinal motility
  • Decreased heart rate
  • Decreased respiratory rate

Estimated Blood Loss

So, remember giving anesthesia will result in a depressed central nervous system. That is why it is important to note the input and output of the client before and after the operation to determine the estimated blood that was lost during the procedure.

Checking the laboratory values is vital when a client comes out of the operating room. To know the estimated blood loss and prevent the client from further bleeding, the nurse-in-charge should check the following coagulation factors:

  • Partial thromboplastin time (PTT)
  • International normalized ratio (INR)
  • Prothrombin time (PT)

Physical Assessment

Aside from the laboratory values, you also have to assess the status of your unconscious client. So, the first thing that you have to do is to observe for the airway, breathing, and circulation (ABC).

Airway and Breathing

Between bleeding out from the incision site to not breathing, your priority is to make sure that the client’s airway is clear and is breathing properly.

Why is airway and breathing the first priority?

We’ve previously mentioned that anesthesia suppresses the central nervous system which is why you have to make sure that the client’s airway is patent and that breathing is normal to promote and facilitate oxygen exchange to the lungs and heart.

Circulation

So, after checking your client’s airway and breathing, the next thing that you have to asses is circulation. Your primary concern is the incision site. You have to ask yourself the following questions while assessing the surgery site:

  • How does the site look?
  • Is there profuse bleeding?

If there’s the presence of bleeding, you are not to remove the initial dressing. You have to call the doctor first and inform him or her about the client’s condition. You also have to take note of the bleeding by outlining the site with a pen at the beginning of the shift so that you can easily assess if there is excessive bleeding if the stain becomes bigger and the dressing becomes soaked.

Site Infection

Assessing for site bleed is usually what happens during the first day postoperatively, together with the ABCs. On the second day, you have to assess for site infection. What are the things that you have to take note of when checking for site infection?

  • The site is warm to touch
  • The site is reddish
  • Drainage or pus is coming out of the site

But what does a normal, acceptable wound bed look like?

Your client’s wound bed has to be clean, dry, and intact. It should be cool to the touch, and the wound should appear pink. This would interpret that the client’s condition is getting better and is considered as a positive outcome.

Infection and Fever

Another sign that your client has infection is when he or she develops a fever. Upon checking the vital signs, clients with fever will manifest an increased body temperature and a skyrocketing heart rate.

Compartment Syndrome

If your client underwent knee or extremity surgery, one of the major assessments that you have to take into consideration is the circulation of sensory and motor functions which is the capillary refill. Capillary refill is blood returning to the distal portions of the body.

If there is insufficient capillary refill, compartment syndrome may occur. Compartment syndrome happens due to increased blood volume around the surgical site caused by inflammation. This inflammation prevents blood from circulating properly and getting through the small vessels of the toes and fingers.

There are two indications of decreased circulation:

  1. If the client is unable to move their affected extremities
  2. If the client cannot sense your touch on that affected area

Remember that one of the most important things that you have to do when focusing with your DAR is gathering sufficient and accurate data to do appropriate action and yield a positive response. Nurses who are unable to gather data correctly, the client might lose his or her foot because oxygen is no longer reaching the extremities.

Assessing for Pain

To know your client’s pain, you have to ask them personally. If they are unable to talk due to the effects of pain medication, make sure that you are assessing the level of consciousness because there might be analgesic overdose which can cause decompression of the brain, lungs, heart, and the GI.

A Summary

Here is a summary of the things that you have to remember when taking care of a post-operative client:

  1. ABC assessment is a top
  2. Level of consciousness and site assessment comes next.
  3. Checking for bleeding and infection happens in the first 24 to 48 hours after surgery.
  4. Compartment syndrome occurs in surgeries concerning the extremities.
  5. Analgesic overdose can result in a depressed CNS.

So, that’s it for the initial assessment done in the PACU. For our next lecture, we’ll go into the details of an ongoing assessment.

Essential Nursing Considerations of Temperature Physiology

Taking the vital signs of your client is one of the most basic things that you should do upon assessment and temperature is the first vital sign that should be taken.

Though the process of taking the temperature of a client seems effortless, there are still nurses who get it wrong, especially when taking into consideration the different protocols for inserting the thermometer. Which is why we’ll be going into the essential information that you should keep in mind when taking your client’s temperature.

Thermometer Routes

Basic knowledge: there are three routes where a thermometer can be inserted, namely:

  • Axilla or the armpit
  • Oral or Sublingual (under the tongue)
  • Rectal

Currently, there are more advanced ways to take the temperature which can be through scanning the forehead or going under the ear.

Among the three routes, the rectal route is the most accurate.

Routes for Ages

When it comes to age, there are a couple of considerations that one must follow:

  1. Adults – orally
  2. Adolescents – axillary
  3. Pediatrics – rectally

In nursing school, you are taught to identify the different types of thermometers with their respective color-coding scheme; therefore, you should never insert a red thermometer in a client’s mouth because those are meant to be inserted in the rectum.

Normal Temperature

The average normal temperature is around 98.7 Fahrenheit. Recently, there have been new standards saying that the normal range is from 97.5 up to 99.1 Fahrenheit. At this point, it depends on the metabolic rate of your client’s body type because there are people who burn calories at a much faster rate while there are those who take time to do so.

What Affects Temperature

There are a couple of things that affect temperature; however, the primary cause is an infection. Infection, no matter where it’s located – toe, lungs, skin, and so on – will have a significant effect on a person’s temperature. Areas infected are usually warm or hot to touch, and for this reason, the client will experience fever.

Sepsis is another factor that affects temperature. If a client becomes septic due to an infection of the blood, it is immediately manifested by increased temperature. Sepsis can be due to numerous factors including:

  • Urinary tract infection (UTI)
  • Pneumonia
  • Cellulitis
  • Diabetes

Sepsis in diabetic clients is common. For this reason, it is necessary that nurses need to watch out for signs and symptoms of sepsis, especially in older clients. If an elderly or geriatric client has sepsis, their immune system is expected to be low. Once that infection hits the bloodstream, it will travel through the entire body, affecting vital organs like the heart, brain, kidneys, etc.

Temperature with Sepsis

Clients who have sepsis are expected to have a temperature ranging from 103 up to 104 Fahrenheit; it can even go up to 105 Fahrenheit. At this point, the body will have its hypothalamus, the thermal regulator device inside the brain, to shut down due to increased heat inside the body. The moment thermal regulation ceases, there will be a drop in body temperature, which is what happens with sepsis.

Sepsis Intervention

The primary goal when you have a client when sepsis, is to bring down their temperature to avoid organ failure immediately. Taking the rectal temperature is advisable to get accurate data on the status of your septic client. In hospitals, there are standard core measures when handling septic workups. It is best to get acquainted as to what these core measures are.

Points to Remember

Here are a couple of things that you have to take into great consideration when getting your client’s temperature:

  1. You should not take the temperature of chemotherapy clients rectally. Chemotherapy shrinks down the tumor and all the while, the process also kills new cells. Therefore, those who are getting chemotherapy have thin epithelial lining especially around the rectal area, and inserting a rectal thermometer may cause complications.
  2. A client undergoing chemotherapy who also has sepsis should not be given a rectal thermometer to avoid bowel perforation.
  3. Axillary thermometers are given to clients who are unable to open their mouths like those who have neurological diseases like MS, ALS, myasthenia gravis, or those with altered level of consciousness.
  4. Among the three thermometer sites, the axillary temperature provides the least accurate data.

So, those are some important nursing considerations when taking the temperature. For other vital signs discussions, you can visit our SimpleNursing website.