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Wound Care 101

Cox, Jill PhD, RN, APN-C, CWOCN

Jill Cox is a clinical associate professor at the Rutgers University School of Nursing in Newark, N.J., and a wound/ostomy/continence advanced practice nurse at Englewood Hospital and Medical Center in Englewood, N.J.

Jill Cox has disclosed an ongoing relationship with Hill Rom International. This article has been reviewed, and all potential or actual conflicts have been resolved. The planners have disclosed no potential conflicts of interest, financial or otherwise.

The clinical nurse may be the first caregiver to assess changes in a patient's skin and initiate wound care. This article provides practical guidelines that any nurse can implement.

The clinical nurse may be the first caregiver to assess changes in a patient's skin and initiate wound care. This article provides practical guidelines that any nurse can implement to support wound healing and improve patient care.

IF A WOUND CARE NURSE is not available, the clinical nurse may be the first caregiver to assess changes in a patient's skin. Managing these changes, including wounds, can be challenging, as patients present with diverse disorders and tissue damage can range from superficial to deep. But by applying a few basic principles, starting with a skin and wound assessment, the nurse can simplify the process and determine an appropriate treatment plan. This article provides practical guidelines that any nurse can implement.

Assessment basics

Successful wound management starts with a thorough assessment of the wound and periwound skin. The assessment should include the following components. 1

• Anatomic location . Location can provide information regarding possible causes of the wound. For example, a wound over the sacral area in a bedbound or immobile patient could be a pressure injury, a wound in a lower extremity with accompanying edema could be a venous ulcer, and a wound on the plantar surface of the foot may be a neuropathic ulcer. 2
• Degree of tissue damage . Determining the degree of tissue damage in a wound will help to guide the care plan and will provide some information regarding the healing trajectory. Wounds can be described as partial thickness , with damage limited to the epidermal and/or dermal layers, or full thickness with damage evident in the subcutaneous layers and below (see Skin anatomy ). For pressure injuries, the staging classification defined by the National Pressure Ulcer Advisory Panel (NPUAP) is used to describe the appearance of the wound and the extent of tissue damage (see Key resources ). 3
• Type of tissue in the wound . Tissue in the wound bed can be described as viable or nonviable. Viable tissue can appear beefy red as with granulation tissue, or light pink in the case of new epithelial tissue. In contrast, the appearance nonviable or necrotic tissue varies: Eschar may be black, brown, or tan; fibrin slough is described as stringy or adherent and yellow in color. 1,4
• Wound size . Describe the size of a wound according to linear dimensions (length times width). Measure a wound's length using the head-toe axis; measure its width from side to side. If the wound has depth, measure from the deepest point of the wound to the wound surface using a sterile cotton-tip applicator.

Assess for sinus tracts (sometimes called tunneling), which can occur in full-thickness wounds. This dead space has the potential for abscess formation. The depth of a sinus tract can be measured by gently probing the area with a sterile cotton-tip applicator. The distance from the visible wound base to the end of the tract indicates the tract's depth. Identify and measure the location of sinus tracts using the analogy of a clock face, with 12:00 pointing toward the patient's head.

Undermining is tissue destruction at the edge of the wound, creating a liplike effect. This can also be measured by gently probing the area with a sterile cotton-tip applicator and recording the location using the clock face analogy. 1,4

• Wound edges and periwound skin . The outer edge of the wound can provide information regarding how long a wound has been present and may even assist in determining the etiology. Wounds over bony prominences with defined edges may be related to pressure. Venous wounds found on the leg are characterized by an irregular shape and undefined edges.

Periwound skin can provide information about other factors that contribute to wound development or nonhealing. For example, weeping or excess wound drainage surrounding a venous ulcer can macerate periwound skin, giving it a wet, waterlogged appearance that may be soft and gray white in color. 5

• Infection . Note the presence or absence of signs and symptoms of local infection (erythema, induration, pain, edema, purulent exudate, wound odor) during the wound assessment. Keep in mind that patients with chronic wounds may not exhibit these classic signs and symptoms of infection due to the presence of biofilm. This extracellular polysaccharide matrix embeds microorganisms, delays healing, and renders infection difficult to diagnose. 6
• Pain . The presence and intensity of pain associated with the wound can provide some important information regarding wound etiology and wound chronicity. However, the degree of pain may not correlate to the extent of injury. Skin tears, for example, can be very painful because damage confined to superficial skin can expose nerve endings in the dermal layer. 7 Conversely, patients with neuropathic ulcers on the plantar aspect of the foot and concomitant peripheral neuropathy may feel little or no pain, even if the wound is grossly infected. 8,9

Identifying wound etiology

After the nurse conducts a thorough assessment of the wound and periwound skin, its etiology may become more evident. Common types of wounds encountered in the acute care setting include pressure injuries, venous ulcers, arterial ulcers, skin tears, diabetic foot wounds, and moisture-associated skin damage (see Common wound types ).

Pressure injuries (formerly known as pressure ulcers) are defined by the NPUAP as localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury results from intense and/or prolonged pressure or pressure combined with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. Pressure injuries are described according to the NPUAP staging system based on damage that is clinically observed. 3

Venous ulcers are related to incompetence of the valves of the lower extremities, allowing blood to reflux into the superficial venous system and causing edema. Incomplete emptying of the deep veins can result in higher-than-normal pressure in the peripheral venous system of the lower extremities, which can eventually result in ulcerations. 10-12

Arterial wounds result from severe tissue ischemia. One of the most common causes of lower extremity arterial disease and ulceration is atherosclerosis of peripheral arterial vessels. 12,13

Diabetic foot wounds are also called neuropathic ulcers. Peripheral neuropathy is present in over 80% of patients with foot ulcers. 8 Neuropathy promotes ulcer formation by altering both pain sensation and pressure perception in the foot. Neuropathy can also alter the microcirculation and impair skin integrity. Once wounds occur, healing may be difficult to achieve, especially in patients with deep tissue or bone infections and in those with diminished blood flow to the foot. 8

A skin tear is defined by the International Skin Tear Advisory Panel (ISTAP) as a traumatic wound caused by mechanical forces (shear, friction, or blunt force), such as the mechanical force required to remove adhesives. Severity may vary by depth but does not extend through the subcutaneous layer. The nurse should use the classification system for skin tears developed by ISTAP to describe the degree of skin damage:

• Type 1: no skin loss; a skin flap can be positioned to cover the exposed wound base.
• Type 2: partial loss of the skin flap.
• Type 3: total loss of the skin flap; entire wound bed is exposed. 7,14

Moisture-associated skin damage (MASD) is defined as the inflammation and erosion of the skin that accompanies exposure to many different types of moisture, such as urine, perspiration, and wound drainage. 15,16 Chronic exposure to moisture macerates the skin, impairing its protective mechanisms and disrupting normal skin flora, which can predispose the patient to cutaneous infections such as candidiasis. Incontinence-associated dermatitis (IAD), a subtype of MASD, is caused by chronic exposure to urine and/or liquid stool. 16,17

Topical therapy: Eight key objectives

Once the wound is assessed and the etiology of the wound has been determined, the nurse can initiate topical therapy. Topical dressings create an environment that fosters the normal healing process. Bryant and Nix outline eight objectives for the caregiver to consider when selecting the most appropriate interventions. 18

1. Prevent and manage infection . One of the primary goals of topical wound care is to protect the wound base from outside contaminants such as bacteria. If infection is evident in the wound, wound cultures should be considered and the need for topical antimicrobial/antiseptic products should be discussed with the primary provider.

Topical antibiotics destroy microorganisms; topical antiseptics inhibit microbial growth. Examples include cadexomer iodine, honey, silver sulfadiazine, and topical antibiotics. These products, which are covered with a secondary dressing, can be used in partial-thickness and full-thickness wounds that are infected or at high risk for infection. They should not be used long-term. 18

2. Cleanse the wound . Routine cleansing should be performed at each dressing change with products that are physiologically compatible with wound tissue. Normal saline is the least cytotoxic; when delivered at a pressure of 4 to 15 PSI, it is adequate to remove wound debris. 19,20 Commercially available wound cleansers can also be used, but avoid hypochlorite solutions, betadine, hydrogen peroxide, and acetic acid in routine wound cleansing as these agents can be cytotoxic to fibroblasts. 19

3. Debride the wound . If necrotic tissue is visible in the wound bed, removal of this devitalized tissue is indicated in most circumstances. One exception to this is stable, dry eschar on the heel. In this circumstance, leaving the eschar in place is recommended until the patient's vascular status can be determined. 19

Wound debridement can be accomplished with several different methods. Autolytic debridement, the slowest form of debridement, is accomplished through use of moist topical dressings that foster autolysis of necrotic tissue. Enzymatic debridement is accomplished by applying the prescribed topical agent directly to the wound bed. It is usually applied daily and covered with a dressing such as gauze, moistened gauze, or foam. Sharp wound debridement may be performed at the bedside (conservative wound debridement) or in the OR (surgical wound debridement) by a qualified healthcare provider. Wounds that are necrotic and showing signs of infection should be treated with sharp/surgical debridement as soon as feasible. 19,21

4. Maintain appropriate moisture in the wound . A moist wound environment has been shown to facilitate wound healing, reduce pain, and decrease wound infection. 19 In wounds that are heavily draining, the nurse should apply the type of dressings that will help absorb excess drainage so that an appropriate level of moisture can be maintained in the wound bed.

5. Eliminate dead space . Wounds that have depth need to be packed. Packing agents, such as normal saline and hydrogel-impregnated dressings, can keep the wound bed moist. In wounds that are too moist, alginate or hydrofiber dressings can help control excess drainage. Packing material should be easy to remove from the wound base during each dressing change to avoid injuring healing tissue.

6. Control odor . To manage odor, if present, the nurse should consult with the provider about the frequency of dressing changes, wound cleansing protocol, and the possible need for debridement or topical antimicrobials. 22,23 The primary healthcare provider or wound care specialist should be consulted regarding treatment options to control wound odor.

7. Manage wound pain . Wounds that are painful should be thoroughly assessed for the presence of infection or other etiology (such as an associated fracture or a foreign object in the wound) and treated accordingly. The use of moisture-retentive dressings can help to decrease pain associated with dressing removal and can also decrease the need for frequent dressing changes in painful wounds. 24

8. Protect periwound skin . Heavily draining wounds or the improper use of a moist dressing can lead to maceration of the periwound skin, altering tissue tolerance and damaging the wound edges. Skin barrier creams/ointments, skin protective wipes, or skin barrier wafers can be used to protect the periwound skin. 18

The selection of an appropriate topical dressing should be guided by the objectives described above. Always follow the manufacturer's guidelines in addition to your facility's policies and procedures for specific use of these products. See Choosing a w ound dressing for more details on common products used in the clinical setting.

Look at the whole picture

Because wounds do not occur in isolation, wound management involves not only the topical care, but also attention to other systemic or local factors that can be contributing to wound development or impaired healing. Consider the following:

• In the case of pressure injuries, minimizing pressure and shear must be part of the treatment plan. 19
• With neuropathic wounds, decreasing the risk of further injury, especially in patients with diminished sensation, is an important educational intervention.
• Controlling lower extremity edema in patients with venous ulcers through compression is a fundamental component of a successful treatment plan. Compression dressings and multilayer bandaging systems are the gold standard for venous ulcers. 11
• Establishing adequate perfusion to the extremity in patients with arterial ulcers is essential to wound healing. Some patients will need revascularization to support healing.
• In patients with skin tears, protecting the skin is a priority, especially in those with fragile skin or other risk factors. 7
• In patients with a history of diabetes mellitus, glycemic control is an important factor to consider in wound development and wound healing. 9

Nutrition is another component of an overall wound treatment plan. The prevalence of malnutrition in the hospitalized population has been cited as between 30% and 50%. 25 Nutrition and hydration are essential to normal cellular function and successful wound healing. Assessing the patient's nutritional status in consultation with the registered dietitian is essential to determine the patient's potential to heal. A nutritional plan should take into consideration the patient's overall health and nutritional status and include appropriate nutritional and micronutrient supplementation. For example, in patients with pressure injuries, 30 to 35 kcal/kg of body weight is recommended daily, as is 1.25 to 1.5 g/kg of protein daily and micronutrient supplementation in patients who have a known or suspected vitamin deficiency. 19,26

Detailed documentation of ongoing assessment findings and interventions serve as an important communication tool for all caregivers, including the wound care professional who will augment and clarify the plan of care.

Follow key principles and guidelines

Nurses can begin managing wounds before a wound care provider is available by keeping in mind the components of a wound assessment, identification of the wound etiology, and the principles of appropriate topical management described here. Wound care performed by the nurse should be guided by the nurse's scope of practice and institutional policy and procedures, based on type of wound and topical agents available in the facility. Other factors such as infection or malnutrition need prompt consideration. These basic early interventions can set the patient on the path to healing.

Treating wounds requires a multidisciplinary approach with the frontline nurse an essential member of this team. When provided with the appropriate resources, the nurse can have a positive impact on the patient's wound healing trajectory.

Key resources

Visit the following websites for more information about skin and wound care.

• International Diabetes Federation: www.idf.org
• International Skin Tear Advisory Panel: www.skintears.org
• National Pressure Ulcer Advisory Panel: www.npuap.org
• World Council of Enterostomal Therapists: www.wcetn.org
• Wound, Ostomy and Continence Nurses Society: www.wocn.org

arterial ulcer; diabetic ulcer; incontinence-associated dermatitis; MASD; moisture-associated skin damage; pressure injury; skin tear; venous ulcer; wound care

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Case series: Shared wound care discussion guide

Shared care encompasses approaches and interventions that may enable patients to participate in care planning, decision making and care delivery. This approach values the patient as an active participant rather than a passive recipient of care, and is a key part of management for a range of other conditions (Wounds International, 2016). Patient involvement can not only improve wound care outcomes, but also reduce the economic burden and improve quality of life (Hibbard and Gilburt, 2014).

Shared wound care extends beyond the patient to engage with the patients’ informal carer(s) (member[s] of a person’s social network, e.g. family, friend or guardian) who helps the individual with activities of daily living, and may assist with the patient’s wound-related care. 

The shared wound care discussion guide (SWCDG) was developed as an aid for clinicians to use with the patient and informal carer(s) to discuss their awareness, willingness and ability to be involved in shared wound care (Moore et al, 2021). The SWCDG builds on international research and guidelines (e.g. Wounds International, 2016) plus survey results from clinicians (Moore and Coggins, 2021) and patients (Moore et al, 2021) that identified educational support is needed for clinicians to help patients and informal carers participate in shared wound care (Miller and Kapp, 2015; Kapp and Santamaria, 2017).

This case series describes how the SWCDG was evaluated in clinical practice by five wound care specialists in Australia, Canada, The Netherlands and the United Kingdom. The SWCDG was used during the initial patient and wound assessment to prompt conversation about shared wound care. The individual wound care dressing regimens were devised in collaboration between the clinician and the patient. The participants fears, concerns and thoughts on shared wound care were recorded. Each patient was monitored and reviewed for approximately 4 weeks or longer. Parameters of wound healing were recorded, such as wound size, wound bed condition and wound progression. 

Overall, clinicians reported that using the SWCDG helped to facilitate shared wound care. The patients and their carers (if applicable) reported feeling more independent and empowered to be involved in their own care. There were decreased clinic visits and regular communication between the patient and clinician. If the patient was in a residential or nursing home, an additional benefit was that the nursing staff were upskilled in their wound care knowledge and felt confident that the patients could take an active role in their own wound care. 

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Wound care evidence, knowledge and education amongst nurses: a semi-systematic literature review

Affiliation.

• 1 School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, Scotland.
• PMID: 29045004
• PMCID: PMC7949797
• DOI: 10.1111/iwj.12822

The aims of this study were to determine the knowledge and skills of nurses involved in wound care, to provide a critical overview of the current evidence base underpinning wound care and to determine the extent of utilisation of existing evidence by nurses involved in the management of wounds in practice. A semi-systematic review of the literature was undertaken on Cinahl, Medline Science Direct and Cochrane using the search terms: wound, tissue viability, education, nurse, with limitations set for dates between 2009 and 2017 and English language. Shortfalls were found in the evidence base underpinning wound care and in links between evidence and practice, prevalence of ritualistic practice and in structured education at pre- and post-registration levels. The evidence underpinning wound care practice should be further developed, including the conduction of independent studies and research of qualitative design to obtain rich data on both patient and clinician experiences of all aspects of wound management. More structured wound care education programmes, both at pre-registration/undergraduate and professional development levels, should be established.

Keywords: Education; Nurse; Tissue Viability; Wound.

© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

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Wound Healing Care Center

Our team is dedicated to your healing and comfort..

Gritman Medical Center offers the most advanced and comprehensive wound healing. Whether your wound is acute or chronic, our team is here to help you heal and get back to normal life.

Our staff is nationally or state-licensed and certified. Many of our wound specialists hold advanced certifications. Our wound healing rate exceeds 91%. Wounds are healed within an average of 30 days. In 2016, Healogics recognized our Wound Healing Center as a Center of Excellence.

Who May Benefit from the Gritman Wound Healing Center?

Any patient with a wound may benefit from specialized wound care. Reasons for Wound Care:

• Diabetic Ulcers
• Neuropathic Ulcers
• Pressure Ulcers
• Ischemic Ulcers
• Venous Insufficiency
• Traumatic Wounds
• Surgical Wounds
• Peristomal Skin Irritations
• Other Chronic, Non-Healing Wounds

We Offer the Following Treatments

• Wound Consultation/Evaluation
• Diagnostic and Ongoing Assessments
• Non-Invasive Vascular Studies
• Specialty Wound Dressings
• Compression Therapy
• Treatment of Wound Infections
• Patient and Family Education
• Pressure Off-Loading Devices and Footwear
• Debridement (Cleaning and Removal of Damaged Tissue)
• Negative Pressure Wound Therapy
• Hyperbaric Oxygen Therapy

A Network of Healing

Gritman Wound Healing Center is a member of the Healogics network. Healogics is the nation’s wound healing expert. Last year, more than 300,000 patients received advanced wound care through a nationwide network of over 600 wound care centers. The Healogics team is made up of almost 3,000 employees, 4,000 affiliated physicians and a Healogics specialty physician practice group of nearly 300. In addition to the company’s network of outpatient centers, Healogics partners with over 300 skilled nursing facilities to care for patients with chronic wounds and provides inpatient consults at more than 80 partner hospitals.

Sharon Cofre, Healogic Wound Care team member, standing next to a monoplace hyperbaric oxygen chamber used for wound healing.

Wound Healing Resources

Diabetes and Wound Care

Caring for your skin when you have diabetes

Try these tips to help prevent dryness, injury and other skin problems.

• Use warm water. Avoid hot water, which can dry out the skin.
• Use a bath soap that has a moisturizer added. Use soap only as needed (on your feet, underarms, and groin). Avoid deodorant soaps and antibacterial soaps. They may dry your skin.
• If your skin is dry, don’t use bubble baths. Use bath oil instead.
• Use a moisturizer after you bathe. But don’t put it on skin folds and between your toes.
• Use a home humidifier during cold weather and in dry climates

Patient Experiences

Did you or a loved one have an amazing experience at Gritman? Share your story !

Steve Corr is forever thankful to the Gritman Wound Healing Center for saving his left foot.

Physicians were worried Corr would lose his toes and the end of his foot following complications after suffering from a broken heel bone. Corr lives with neuropathy in his feet – a condition that prevents him from feeling pain – and the results of a hard cast left his foot permanently damaged. Eleven months later, Corr was recently cleared to return to daily life in what his providers have described to him as a “miracle.”

Read Steve Corr’s Experience

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Management and Professional Concepts [Internet].

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Chapter 2 - Prioritization

2.1. prioritization introduction, learning objectives.

• Prioritize nursing care based on patient acuity

• Use principles of time management to organize work

• Analyze effectiveness of time management strategies

• Use critical thinking to prioritize nursing care for patients

• Apply a framework for prioritization (e.g., Maslow, ABCs)

“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is “not enough of them to go around.”

The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands.[ 1 ] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.

A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role.[ 2 ] How can we address this professional dilemma and enhance the novice nurse’s successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.

Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.

2.2. TENETS OF PRIORITIZATION

Prioritization.

As new nurses begin their career, they look forward to caring for others, promoting health, and saving lives. However, when entering the health care environment, they often discover there are numerous and competing demands for their time and attention. Patient care is often interrupted by call lights, rounding physicians, and phone calls from the laboratory department or other interprofessional team members. Even individuals who are strategic and energized in their planning can feel frustrated as their task lists and planned patient-care activities build into a long collection of “to dos.”

Without utilization of appropriate prioritization strategies, nurses can experience  time scarcity , a feeling of racing against a clock that is continually working against them. Functioning under the burden of time scarcity can cause feelings of frustration, inadequacy, and eventually burnout. Time scarcity can also impact patient safety, resulting in adverse events and increased mortality.[ 1 ] Additionally, missed or rushed nursing activities can negatively impact patient satisfaction scores that ultimately affect an institution’s reimbursement levels.

It is vital for nurses to plan patient care and implement their task lists while ensuring that critical interventions are safely implemented first. Identifying priority patient problems and implementing priority interventions are skills that require ongoing cultivation as one gains experience in the practice environment.[ 2 ] To develop these skills, students must develop an understanding of organizing frameworks and prioritization processes for delineating care needs. These frameworks provide structure and guidance for meeting the multiple and ever-changing demands in the complex health care environment.

Let’s consider a clinical scenario in the following box to better understand the implications of prioritization and outcomes.

Imagine you are beginning your shift on a busy medical-surgical unit. You receive a handoff report on four medical-surgical patients from the night shift nurse:

• Patient A is a 34-year-old total knee replacement patient, post-op Day 1, who had an uneventful night. It is anticipated that she will be discharged today and needs patient education for self-care at home.

• Patient B is a 67-year-old male admitted with weakness, confusion, and a suspected urinary tract infection. He has been restless and attempting to get out of bed throughout the night. He has a bed alarm in place.

• Patient C is a 49-year-old male, post-op Day 1 for a total hip replacement. He has been frequently using his patient-controlled analgesia (PCA) pump and last rated his pain as a “6.”

• Patient D is a 73-year-old male admitted for pneumonia. He has been hospitalized for three days and receiving intravenous (IV) antibiotics. His next dose is due in an hour. His oxygen requirements have decreased from 4 L/minute of oxygen by nasal cannula to 2 L/minute by nasal cannula.

Based on the handoff report you received, you ask the nursing assistant to check on Patient B while you do an initial assessment on Patient D. As you are assessing Patient D’s oxygenation status, you receive a phone call from the laboratory department relating a critical lab value on Patient C, indicating his hemoglobin is low. The provider calls and orders a STAT blood transfusion for Patient C. Patient A rings the call light and states she and her husband have questions about her discharge and are ready to go home. The nursing assistant finds you and reports that Patient B got out of bed and experienced a fall during the handoff reports.

It is common for nurses to manage multiple and ever-changing tasks and activities like this scenario, illustrating the importance of self-organization and priority setting. This chapter will further discuss the tools nurses can use for prioritization.

2.3. TOOLS FOR PRIORITIZING

Prioritization of care for multiple patients while also performing daily nursing tasks can feel overwhelming in today’s fast-paced health care system. Because of the rapid and ever-changing conditions of patients and the structure of one’s workday, nurses must use organizational frameworks to prioritize actions and interventions. These frameworks can help ease anxiety, enhance personal organization and confidence, and ensure patient safety.

Acuity and intensity are foundational concepts for prioritizing nursing care and interventions.  Acuity  refers to the level of patient care that is required based on the severity of a patient’s illness or condition. For example, acuity may include characteristics such as unstable vital signs, oxygenation therapy, high-risk IV medications, multiple drainage devices, or uncontrolled pain. A “high-acuity” patient requires several nursing interventions and frequent nursing assessments.

Intensity addresses the time needed to complete nursing care and interventions such as providing assistance with activities of daily living (ADLs), performing wound care, or administering several medication passes. For example, a “high-intensity” patient generally requires frequent or long periods of psychosocial, educational, or hygiene care from nursing staff members. High-intensity patients may also have increased needs for safety monitoring, familial support, or other needs.[ 1 ]

Many health care organizations structure their staffing assignments based on acuity and intensity ratings to help provide equity in staff assignments. Acuity helps to ensure that nursing care is strategically divided among nursing staff. An equitable assignment of patients benefits both the nurse and patient by helping to ensure that patient care needs do not overwhelm individual staff and safe care is provided.

Organizations use a variety of systems when determining patient acuity with rating scales based on nursing care delivery, patient stability, and care needs. See an example of a patient acuity tool published in the  American Nurse  in Table 2.3 .[ 2 ] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable patient requiring minimal individualized nursing care and intervention. A rating of 2 reflects a patient with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex patient who requires frequent intervention and assessment. This patient might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk patient. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a patient with a rating of 1 or 2. [3]

Example of a Patient Acuity Tool [ 4 ]

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Read more about using a  patient acuity tool on a medical-surgical unit.

Rating scales may vary among institutions, but the principles of the rating system remain the same. Organizations include various patient care elements when constructing their staffing plans for each unit. Read more information about staffing models and acuity in the following box.

Staffing Models and Acuity

Organizations that base staffing on acuity systems attempt to evenly staff patient assignments according to their acuity ratings. This means that when comparing patient assignments across nurses on a unit, similar acuity team scores should be seen with the goal of achieving equitable and safe division of workload across the nursing team. For example, one nurse should not have a total acuity score of 6 for their patient assignments while another nurse has a score of 15. If this situation occurred, the variation in scoring reflects a discrepancy in workload balance and would likely be perceived by nursing peers as unfair. Using  acuity-rating staffing models  is helpful to reflect the individualized nursing care required by different patients.

Alternatively, nurse staffing models may be determined by staffing ratio.  Ratio-based staffing models  are more straightforward in nature, where each nurse is assigned care for a set number of patients during their shift. Ratio-based staffing models may be useful for administrators creating budget requests based on the number of staff required for patient care, but can lead to an inequitable division of work across the nursing team when patient acuity is not considered. Increasingly complex patients require more time and interventions than others, so a blend of both ratio and acuity-based staffing is helpful when determining staffing assignments.[ 5 ]

As a practicing nurse, you will be oriented to the elements of acuity ratings within your health care organization, but it is also important to understand how you can use these acuity ratings for your own prioritization and task delineation. Let’s consider the Scenario B in the following box to better understand how acuity ratings can be useful for prioritizing nursing care.

You report to work at 6 a.m. for your nursing shift on a busy medical-surgical unit. Prior to receiving the handoff report from your night shift nursing colleagues, you review the unit staffing grid and see that you have been assigned to four patients to start your day. The patients have the following acuity ratings:

Patient A: 45-year-old patient with paraplegia admitted for an infected sacral wound, with an acuity rating of 4.

Patient B: 87-year-old patient with pneumonia with a low grade fever of 99.7 F and receiving oxygen at 2 L/minute via nasal cannula, with an acuity rating of 2.

Patient C: 63-year-old patient who is postoperative Day 1 from a right total hip replacement and is receiving pain management via a PCA pump, with an acuity rating of 2.

Patient D: 83-year-old patient admitted with a UTI who is finishing an IV antibiotic cycle and will be discharged home today, with an acuity rating of 1.

Based on the acuity rating system, your patient assignment load receives an overall acuity score of 9. Consider how you might use their acuity ratings to help you prioritize your care. Based on what is known about the patients related to their acuity rating, whom might you identify as your care priority? Although this can feel like a challenging question to answer because of the many unknown elements in the situation using acuity numbers alone, Patient A with an acuity rating of 4 would be identified as the care priority requiring assessment early in your shift.

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other patient needs impact prioritization.

Maslow’s Hierarchy of Needs

When thinking back to your first nursing or psychology course, you may recall a historical theory of human motivation based on various levels of human needs called Maslow’s Hierarchy of Needs.  Maslow’s Hierarchy of Needs  reflects foundational human needs with progressive steps moving towards higher levels of achievement. This hierarchy of needs is traditionally represented as a pyramid with the base of the pyramid serving as essential needs that must be addressed before one can progress to another area of need.[ 6 ] See Figure 2.1  [ 7 ] for an illustration of Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs places physiological needs as the foundational base of the pyramid.[ 8 ] Physiological needs include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second level of Maslow’s hierarchy reflects safety needs. Safety needs include elements that keep individuals safe from harm. Examples of safety needs in health care include fall precautions. The third level of Maslow’s hierarchy reflects emotional needs such as love and a sense of belonging. These needs are often reflected in an individual’s relationships with family members and friends. The top two levels of Maslow’s hierarchy include esteem and self-actualization. An example of addressing these needs in a health care setting is helping an individual build self-confidence in performing blood glucose checks that leads to improved self-management of their diabetes.

So how does Maslow’s theory impact prioritization? To better understand the application of Maslow’s theory to prioritization, consider Scenario C in the following box.

You are an emergency response nurse working at a local shelter in a community that has suffered a devastating hurricane. Many individuals have relocated to the shelter for safety in the aftermath of the hurricane. Much of the community is still without electricity and clean water, and many homes have been destroyed. You approach a young woman who has a laceration on her scalp that is bleeding through her gauze dressing. The woman is weeping as she describes the loss of her home stating, “I have lost everything! I just don’t know what I am going to do now. It has been a day since I have had water or anything to drink. I don’t know where my sister is, and I can’t reach any of my family to find out if they are okay!”

Despite this relatively brief interaction, this woman has shared with you a variety of needs. She has demonstrated a need for food, water, shelter, homeostasis, and family. As the nurse caring for her, it might be challenging to think about where to begin her care. These thoughts could be racing through your mind:

Should I begin to make phone calls to try and find her family? Maybe then she would be able to calm down.

Should I get her on the list for the homeless shelter so she wouldn’t have to worry about where she will sleep tonight?

She hasn’t eaten in awhile; I should probably find her something to eat.

All of these needs are important and should be addressed at some point, but Maslow’s hierarchy provides guidance on what needs must be addressed first. Use the foundational level of Maslow’s pyramid of physiological needs as the top priority for care. The woman is bleeding heavily from a head wound and has had limited fluid intake. As the nurse caring for this patient, it is important to immediately intervene to stop the bleeding and restore fluid volume. Stabilizing the patient by addressing her physiological needs is required before undertaking additional measures such as contacting her family. Imagine if instead you made phone calls to find the patient’s family and didn’t address the bleeding or dehydration – you might return to a severely hypovolemic patient who has deteriorated and may be near death. In this example, prioritizing emotional needs above physiological needs can lead to significant harm to the patient.

Although this is a relatively straightforward example, the principles behind the application of Maslow’s hierarchy are essential. Addressing physiological needs before progressing toward additional need categories concentrates efforts on the most vital elements to enhance patient well-being. Maslow’s hierarchy provides the nurse with a helpful framework for identifying and prioritizing critical patient care needs.

Airway, breathing, and circulation, otherwise known by the mnemonic “ABCs,” are another foundational element to assist the nurse in prioritization. Like Maslow’s hierarchy, using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life. If a patient does not have a patent airway, is unable to breathe, or has inadequate circulation, very little of what else we do matters. The patient’s  ABCs  are reflected in Maslow’s foundational level of physiological needs and direct critical nursing actions and timely interventions. Let’s consider Scenario D in the following box regarding prioritization using the ABCs and the physiological base of Maslow’s hierarchy.

You are a nurse on a busy cardiac floor charting your morning assessments on a computer at the nurses’ station. Down the hall from where you are charting, two of your assigned patients are resting comfortably in Room 504 and Room 506. Suddenly, both call lights ring from the rooms, and you answer them via the intercom at the nurses’ station.

Room 504 has an 87-year-old male who has been admitted with heart failure, weakness, and confusion. He has a bed alarm for safety and has been ringing his call bell for assistance appropriately throughout the shift. He requires assistance to get out of bed to use the bathroom. He received his morning medications, which included a diuretic about 30 minutes previously, and now reports significant urge to void and needs assistance to the bathroom.

Room 506 has a 47-year-old woman who was hospitalized with new onset atrial fibrillation with rapid ventricular response. The patient underwent a cardioversion procedure yesterday that resulted in successful conversion of her heart back into normal sinus rhythm. She is reporting via the intercom that her “heart feels like it is doing that fluttering thing again” and she is having chest pain with breathlessness.

Based upon these two patient scenarios, it might be difficult to determine whom you should see first. Both patients are demonstrating needs in the foundational physiological level of Maslow’s hierarchy and require assistance. To prioritize between these patients’ physiological needs, the nurse can apply the principles of the ABCs to determine intervention. The patient in Room 506 reports both breathing and circulation issues, warning indicators that action is needed immediately. Although the patient in Room 504 also has an urgent physiological elimination need, it does not overtake the critical one experienced by the patient in Room 506. The nurse should immediately assess the patient in Room 506 while also calling for assistance from a team member to assist the patient in Room 504.

Prioritizing what should be done and when it can be done can be a challenging task when several patients all have physiological needs. Recently, there has been professional acknowledgement of the cognitive challenge for novice nurses in differentiating physiological needs. To expand on the principles of prioritizing using the ABCs, the CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.[ 9 ]

“Critical” patient needs require immediate action. Examples of critical needs align with the ABCs and Maslow’s physiological needs, such as symptoms of respiratory distress, chest pain, and airway compromise. No matter the complexity of their shift, nurses can be assured that addressing patients’ critical needs is the correct prioritization of their time and energies.

After critical patient care needs have been addressed, nurses can then address “urgent” needs. Urgent needs are characterized as needs that cause patient discomfort or place the patient at a significant safety risk.[ 10 ]

The third part of the CURE hierarchy reflects “routine” patient needs. Routine patient needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine patient needs. Examples of routine daily nursing care include actions such as administering medication and performing physical assessments.[ 11 ] Although a nurse’s typical shift in a hospital setting includes these routine patient needs, they do not supersede critical or urgent patient needs.

The final component of the CURE hierarchy is known as “extras.” Extras refer to activities performed in the care setting to facilitate patient comfort but are not essential.[ 12 ] Examples of extra activities include providing a massage for comfort or washing a patient’s hair. If a nurse has sufficient time to perform extra activities, they contribute to a patient’s feeling of satisfaction regarding their care, but these activities are not essential to achieve patient outcomes.

Let’s apply the CURE mnemonic to patient care in the following box.

If we return to Scenario D regarding patients in Room 504 and 506, we can see the patient in Room 504 is having urgent needs. He is experiencing a physiological need to urgently use the restroom and may also have safety concerns if he does not receive assistance and attempts to get up on his own because of weakness. He is on a bed alarm, which reflects safety considerations related to his potential to get out of bed without assistance. Despite these urgent indicators, the patient in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent patient deterioration. The patient in Room 506 with a rapid, fluttering heartbeat and shortness of breath has a critical need because without prompt assessment and intervention, their condition could rapidly decline and become fatal.

In addition to using the identified frameworks and tools to assist with priority setting, nurses must also look at their patients’ data cues to help them identify care priorities.  Data cues  are pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition. For example, have the patient’s vital signs worsened over the last few hours? Is there a new laboratory result that is concerning? Data cues are used in conjunction with prioritization frameworks to help the nurse holistically understand the patient’s current status and where nursing interventions should be directed. Common categories of data clues include acute versus chronic conditions, actual versus potential problems, unexpected versus expected conditions, information obtained from the review of a patient’s chart, and diagnostic information.

Acute Versus Chronic Conditions

A common data cue that nurses use to prioritize care is considering if a condition or symptom is acute or chronic.  Acute conditions  have a sudden and severe onset. These conditions occur due to a sudden illness or injury, and the body often has a significant response as it attempts to adapt.  Chronic conditions  have a slow onset and may gradually worsen over time. The difference between an acute versus a chronic condition relates to the body’s adaptation response. Individuals with chronic conditions often experience less symptom exacerbation because their body has had time to adjust to the illness or injury. Let’s consider an example of two patients admitted to the medical-surgical unit complaining of pain in Scenario E in the following box.

As part of your patient assignment on a medical-surgical unit, you are caring for two patients who both ring the call light and report pain at the start of the shift. Patient A was recently admitted with acute appendicitis, and Patient B was admitted for observation due to weakness. Not knowing any additional details about the patients’ conditions or current symptoms, which patient would receive priority in your assessment? Based on using the data cue of acute versus chronic conditions, Patient A with a diagnosis of acute appendicitis would receive top priority for assessment over a patient with chronic pain due to osteoarthritis. Patients experiencing acute pain require immediate nursing assessment and intervention because it can indicate a change in condition. Acute pain also elicits physiological effects related to the stress response, such as elevated heart rate, blood pressure, and respiratory rate, and should be addressed quickly.

Actual Versus Potential Problems

Nursing diagnoses and the nursing care plan have significant roles in directing prioritization when interpreting assessment data cues.  Actual problems  refer to a clinical problem that is actively occurring with the patient. A  risk problem  indicates the patient may potentially experience a problem but they do not have current signs or symptoms of the problem actively occurring.

Consider an example of prioritizing actual and potential problems in Scenario F in the following box.

A 74-year-old woman with a previous history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital for pneumonia. She has generalized weakness, a weak cough, and crackles in the bases of her lungs. She is receiving IV antibiotics, fluids, and oxygen therapy. The patient can sit at the side of the bed and ambulate with the assistance of staff, although she requires significant encouragement to ambulate.

Nursing diagnoses are established for this patient as part of the care planning process. One nursing diagnosis for this patient is  Ineffective Airway Clearance . This nursing diagnosis is an actual problem because the patient is currently exhibiting signs of poor airway clearance with an ineffective cough and crackles in the lungs. Nursing interventions related to this diagnosis include coughing and deep breathing, administering nebulizer treatment, and evaluating the effectiveness of oxygen therapy. The patient also has the nursing diagnosis  Risk for   Skin Breakdown  based on her weakness and lack of motivation to ambulate. Nursing interventions related to this diagnosis include repositioning every two hours and assisting with ambulation twice daily.

The established nursing diagnoses provide cues for prioritizing care. For example, if the nurse enters the patient’s room and discovers the patient is experiencing increased shortness of breath, nursing interventions to improve the patient’s respiratory status receive top priority before attempting to get the patient to ambulate.

Although there may be times when risk problems may supersede actual problems, looking to the “actual” nursing problems can provide clues to assist with prioritization.

Unexpected Versus Expected Conditions

In a similar manner to using acute versus chronic conditions as a cue for prioritization, it is also important to consider if a client’s signs and symptoms are “expected” or “unexpected” based on their overall condition.  Unexpected conditions  are findings that are not likely to occur in the normal progression of an illness, disease, or injury.  Expected conditions  are findings that are likely to occur or are anticipated in the course of an illness, disease, or injury. Unexpected findings often require immediate action by the nurse.

Let’s apply this tool to the two patients previously discussed in Scenario E. As you recall, both Patient A (with acute appendicitis) and Patient B (with weakness and diagnosed with osteoarthritis) are reporting pain. Acute pain typically receives priority over chronic pain. But what if both patients are also reporting nausea and have an elevated temperature? Although these symptoms must be addressed in both patients, they are “expected” symptoms with acute appendicitis (and typically addressed in the treatment plan) but are “unexpected” for the patient with osteoarthritis. Critical thinking alerts you to the unexpected nature of these symptoms in Patient B, so they receive priority for assessment and nursing interventions.

Handoff Report/Chart Review

Additional data cues that are helpful in guiding prioritization come from information obtained during a handoff nursing report and review of the patient chart. These data cues can be used to establish a patient’s baseline status and prioritize new clinical concerns based on abnormal assessment findings. Let’s consider Scenario G in the following box based on cues from a handoff report and how it might be used to help prioritize nursing care.

Imagine you are receiving the following handoff report from the night shift nurse for a patient admitted to the medical-surgical unit with pneumonia:

At the beginning of my shift, the patient was on room air with an oxygen saturation of 93%. She had slight crackles in both bases of her posterior lungs. At 0530, the patient rang the call light to go to the bathroom. As I escorted her to the bathroom, she appeared slightly short of breath. Upon returning the patient to bed, I rechecked her vital signs and found her oxygen saturation at 88% on room air and respiratory rate of 20. I listened to her lung sounds and noticed more persistent crackles and coarseness than at bedtime. I placed the patient on 2 L/minute of oxygen via nasal cannula. Within 5 minutes, her oxygen saturation increased to 92%, and she reported increased ease in respiration.

Based on the handoff report, the night shift nurse provided substantial clinical evidence that the patient may be experiencing a change in condition. Although these changes could be attributed to lack of lung expansion that occurred while the patient was sleeping, there is enough information to indicate to the oncoming nurse that follow-up assessment and interventions should be prioritized for this patient because of potentially worsening respiratory status. In this manner, identifying data cues from a handoff report can assist with prioritization.

Now imagine the night shift nurse had not reported this information during the handoff report. Is there another method for identifying potential changes in patient condition? Many nurses develop a habit of reviewing their patients’ charts at the start of every shift to identify trends and “baselines” in patient condition. For example, a chart review reveals a patient’s heart rate on admission was 105 beats per minute. If the patient continues to have a heart rate in the low 100s, the nurse is not likely to be concerned if today’s vital signs reveal a heart rate in the low 100s. Conversely, if a patient’s heart rate on admission was in the 60s and has remained in the 60s throughout their hospitalization, but it is now in the 100s, this finding is an important cue requiring prioritized assessment and intervention.

Diagnostic Information

Diagnostic results are also important when prioritizing care. In fact, the National Patient Safety Goals from The Joint Commission include prompt reporting of important test results. New abnormal laboratory results are typically flagged in a patient’s chart or are reported directly by phone to the nurse by the laboratory as they become available. Newly reported abnormal results, such as elevated blood levels or changes on a chest X-ray, may indicate a patient’s change in condition and require additional interventions. For example, consider Scenario H in which you are the nurse providing care for five medical-surgical patients.

You completed morning assessments on your assigned five patients. Patient A previously underwent a total right knee replacement and will be discharged home today. You are about to enter Patient A’s room to begin discharge teaching when you receive a phone call from the laboratory department, reporting a critical hemoglobin of 6.9 gm/dL on Patient B. Rather than enter Patient A’s room to perform discharge teaching, you immediately reprioritize your care. You call the primary provider to report Patient B’s critical hemoglobin level and determine if additional intervention, such as a blood transfusion, is required.

2.4. CRITICAL THINKING AND CLINICAL REASONING

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action.  Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [2]

When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.

Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action.  Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[ 2 ]

2.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among  C ritical needs,  U rgent needs,  R outine needs, and  E xtras.

You are the nurse caring for the patients in the following table. For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

II. GLOSSARY

Airway, breathing, and circulation.

Nursing problems currently occurring with the patient.

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

Conditions having a sudden onset.

Conditions that have a slow onset and may gradually worsen over time.

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[ 1 ]

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 2 ]

A strategy for prioritization based on identifying “critical” needs, “urgent” needs, “routine” needs, and “extras.”

Pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progr ess toward higher levels.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

A prioritization strategy including the review of planned tasks and allocation of time believed to be required to complete each task.

A feeling of racing against a clock that is continually working against you.

Conditions that are not likely to occur in the normal progression of an illness, disease, or injury.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 - Prioritization.
• PDF version of this title (18M)

In this Page

• PRIORITIZATION INTRODUCTION
• TENETS OF PRIORITIZATION
• TOOLS FOR PRIORITIZING
• CRITICAL THINKING AND CLINICAL REASONING
• LEARNING ACTIVITIES

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