Prioritization and Delegation 1
Mark Klimek NCLEX Review
Delegation and Prioritization
Prioritization
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
Determine who is healthiest or sickest
o Know what you’re looking for
4 parts
o Age, gender, diagnosis, modifying phrase
 “10-year-old male with hypospadias who is vomiting bile-stained emesis.”
 Age and gender are not important in prioritization
 Modifying phrase is more important than diagnosis
 Stable vs unstable
4 Rules for Prioritization
1. Acute beats chronic, it’s not ABC
a. COPD, CHF, and appendicitis
b. Appendicitis would be higher priority because COPD and CHF are chronic conditions
i. With ABC, COPD would be higher priority and it would be wrong
2. Fresh post-op (12 hours) beats medical or other surgical
a. 2-hour post lap cholecystectomy, 2-day post CABG, acute appendicitis, radical neck
dissection, and bilateral AKA, right frontal craniotomy
i. 2-hour post lap cholecystectomy would be priority
3. Unstable beats stable
STABLE
Use of the word “stable”
Chronic illness
Post-op >12 hours
Local or regional anesthesia
Lab abnormalities of an A or B level
(potassium vs creatinine)
Phrases:
“ready for discharge”
“to be discharged”
“admitted longer than 24 hrs ago”
UNSTABLE
Use of the word “unstable”
Acute illness
Post-op <12 hours
General anesthesia (in first 12 hrs)
Lab abnormalities of a C or a D level
(potassium vs creatinine)
Phrases:
“not ready for discharge”
“newly admitted”
“newly diagnosed”
“admitted less than 24 hrs ago”
Change in assessments
Experiencing unexpected s/s of the disease
with which they were diagnosed
Ex: Mild pain with CXR
Unchanged assessments
Experiencing the typical expected s/s of the
disease with which they were diagnosed
Ex: Severe pain w/renal stones
4. The more vital the organ, the higher the priority
o Organ of modifying phrase, not diagnosis.
o Order of Vitality
 Brain, lung, heart, liver, kidney, pancreas
Prioritization and Delegation 2
Things that are Always Unstable:
 Hemorrhage even if unexpected
o Not the same as bleeding, depends on if expected or not
 High fevers over 105°F
o Seizure risk
 Hypoglycemia
 Pulseless or breathless
o Except at the scene at an unwitnessed accident (Dead = lowest priority)
o At witnessed, then highest priority
3 Things that Result in a Black Tag in an Unwitnessed Accident
 Pulseless
 Breathless
 Fixed and dilated pupils (even if still breathing)
Who is the highest priority?
A. 23-year-old male with CHF with potassium of 6.6 and no EKG changes.
B. A chronic renal failure with a creatinine of 24.7 and pink frothy sputum.
C. A client with acute hepatitis with jaundice and increased ammonia level who you cannot arouse.
Rationale: All clients are unstable but C is most unstable because of order of vitality of organs. A is
unstable relating to the heart, B is unstable relating to the lung, and C is unstable relating to the brain.
Which client is a higher priority?
A. 16-year-old female with meningococcal meningitis who has had a temp of 103.8 since admission
3 days ago.
B. 67-year-old male with irritable bowel syndrome who spiked a temp of 100.3 this afternoon.
Rationale: Meningococcal meningitis is an acute condition and IBS is a chronic condition. “Who has had”
refers to an unchanged assessment, temp of 103.8 is expected, and admission is 3 days ago, which
makes her low priority overall. “Spiked” refers to change and temp of 100.3 is unexpected for IBS, and
occurred this afternoon which is a new change. B is higher priority overall.
Prioritization and Delegation 3
Delegation
Do not delegate the following responsibilities to a LPN
 Starting an IV (do not assume they have certification)
 Hanging or mixing IV medications
 Pushing IV push meds
o Can maintain and document flow
 Administer blood or mess with central lines
 Plan of care
 Perform or develop teaching
o Can reinforce
 Care of unstable patients
 Do the first of anything (first dressing, first NGT feeding, first ambulation after surgery)
 The following assessments:
o Admission, transfer, discharge, first assessment after a change
Do not delegate the following responsibilities to a UAP
 Charting about the patient (only what they’ve done)
 Give medications except for topical OTC barrier creams
 Assessments except for VS and accu-checks
 Treatments except for enemas
Do not delegate to the family
 Safety responsibilities
o Family asks to remove restraints while family is there = NO!
o Can delegate to a sitter, but can only do what you’ve taught them to do and document
 Mother can give insulin to 3-year-old, but you have to teach them and
document and evaluate competency
Inappropriate Behavior of Staff [not prioritization/delegation]


Usually 4 answers
o Tell supervisor
o Confront them and take over
o At a later date, talk to them about it
o Ignore it  it’s NEVER this one.
Ask yourself
o Is what they’re doing illegal?
 If yes, tell supervisor
 If no, next question
o Is the patient or staff member in immediate danger of physical/psychological harm?
 If yes, confront them (safety). Tell supervisor later.
 If illegal and harmful, do both, but first intervene then tell supervisor.
 If no, next question.
o Is this behavior legal, not harmful, but simply inappropriate?
 If yes, approach later.
Prioritization and Delegation 4

Example:
o As a LPN, you suspect that a RN is diverting narcotics for private sale?
 Tell supervisor.
o You walk by the room of a patient and an aide is giving perineal care. The aide is not
wearing gloves.
 Confront them/take over.
o You notice an RN going home every day with bulging pockets.
 Could be illegal/stealing. Tell supervisor.
o You’re a circulating nurse in the OR and observe the surgeon breaking sterility.
 Confront.
Auscultating Heart Sounds (“APE-To-Man”)
 Aortic – 2nd intercostal space at right sternal border
 Pulmonic – 2nd intercostal space at left sternal border
 Erb’s point – 3rd intercoastal space at left sternal border
 Tricuspid – 4th/5th intercostal space at the left sternal border
 Mitral – 5th intercostal space in the mid-clavicular line
Nutrition
 Grilled chicken is usually the answer.
 Do not pick casserole for kids, they won’t eat it.
 Finger foods for toddlers.