Prioritization Case Study
You are working night shift on a medical/surgical unit caring for 8 patients. There is another nurse on the
unit that has a similar assignment. There is one nurse’s aide on the unit to help both of you.
Below is the list of your patients with their diagnosis, PMH as well as the admitting MD:
Patient Age
Admitting Diagnosis
PMH
Doctor
84-year-old
62-year-old
77-year-old
82-year-old
44-year-old
88-year-old
57-year-old
68-year-old
confused w/urosepsis
CVA: right hemiparesis
c/o weakness
GI bleed
3 days s/p colectomy
CHF
chronic pancreatitis
newly dx Type II DM
CAD, dementia
HTN, DM Type II
No significant PMH
Ulcerative Colitis, stress
Crohn’s Disease
CAD, HTN, MI x 2
ETOH,
Depression,
Dr. C. M. Pea
Dr. C.T. Scanner
Dr. Ima Guessin
Dr. U. L. Ceration
Dr. Kuttem
Dr. Dryem
Dr. Paenfle
Dr. Sweeten
1. 62-year-old patient with a CVA: right hemiparesis; Dr. C.T. Scanner
0010
You finally get in to see this patient and you have difficulty arousing her. She barely arouses to painful
stimuli. You notice that she has minimal movement of all extremities and her vocalizations are unintelligible.
Her midnight vitals were BP 210/122, HR 88, RR 12 and Temp of 36.8°
2. 77-year-old patient with c/o weakness; Dr. Ima Guessin
0100
This patient is complaining of not being able to get to sleep. He states that he usually takes something at
home every night to help him sleep. He wants you to call the doctor and get something for him.
3. 84-year-old confused patient with urosepsis; Dr. C. M. Pea
0210
Aide comes to tell you that the patient is very confused, trying to get out of bed…” was a little confused at the
beginning of the shift but nothing like this”. The patient is now screaming that people are ‘trying to kill him’
and waking up all the other patients on the unit. You need to notify the doctor of this change…what are you
going to tell him/her? Unable to get vital signs or assessment at this time.
4. 88-year-old patient with CHF; Dr. Dryem
0245
The patient calls you in to tell you that she is having difficulty ‘getting enough air’. You notice that her
respirations are much more labored and wet sounding than your earlier assessment.
5. 82-year-old patient with GI bleed; Dr. Butts
0330
The aide tells you that she just got this patient back to bed after needing to use the bathroom. The patient was
weak and shaky on the way back to bed, stating he thought he was going to pass out. Now feels better after
lying down. His vitals were stable at midnight.
6. 44-year-old patient 3days s/p colectomy; Dr. Kuttem
0400
The aide comes to tell you that the patient’s vital signs are different than when she took them at midnight.
The temperature is now 103.8 with a pulse of 126.
7. 57-year-old patient with chronic pancreatitis; Dr. Paenfle
0430
The aide comes to tell you that your patient is getting dressed in the room and says he is ‘going home’
because he can’t get enough pain relief here. You are unable to give more pain medication at this time. The
patient wants to sign out AMA unless something is done.
8. 68-year-old patient with newly diagnosed Type II DM; Dr. Sweeten
0545
The aide comes to tell you that the patient’s CBG is 408 and the patient is sleepy. You have an order for
sliding scale insulin coverage, but the order says to notify the MD for any blood glucose > 400.
Questions
1. What are your initial priorities for each one of these patients?
For the 84 y.o. pt with urosepsis, my priorities would be to initially assess for a fever, obtain a urine
specimen for a culture, administer antibiotics intravenously or orally as prescribed after the 3-5
day afrebrile period.
For the 62 y.o. pt with CVA: right hemiparesis, my priorities would be to initially assess for airway
patency, slow and bounding pulse rate, cheyne-stokes respirations, hypertension, facial drooping,
dysphagia, and speech, writing changes, and cranial nerves V, VII, IX, X, and XII, etc.
For the 77 c/o weakness, my priorities would be to initially assess through Palliative questions:
such as what brings it on? What were you doing when you first noticed it? What makes it better?
Worse? Quality: How does it feel? How intense/severe is it? Region: Where is it? Does it spread
anywhere? Severity Scale: How bad is it on a scale of 1-10? Is it getting better, worse, staying the
same? Timing: Onset, exactly when did it firs occur? Duration: how long did it last? Frequency,
how often
does it occur? Understand Patient’s Perception of the problem: what do you think it means?
For the 82 y.o. with GI bleeds, my priorities would be to initially asses vital signs, signs of
bleeding, pain, hematemesis, signs of anemia such as weakness, fatigue, hemoglobin and
hematocrit levels
For the 44 y.o. with 3 days s/p colectomy, my priorities would be to Monitor for infection and pain.
I would initially assess the site for abnormal bleeding, fever, increase pulse rate, tachycardia. Also,
I would listen to bowel sounds, monitor intake/output and frequently assess pain levels, and
administer pain medication
For the 88 y.o. with CHF, my priorities would be to assess pulmonary edema, such as restlessness,
anxiety, increased crackles, tachypnea, tachycardia, pink frothy sputum. Also, chronic fatigue, heart
rhythm/sounds, pulse rate
For the 57 y.o. with chronic pancreatitis, my priorities would be to assess for abdominal
pain/tenderness in the left upper quadrant, steatorrhea, foul-smelling stools, weight loss, jaundice
and signs of diabetes mellitus
For the 68 y.o. newly dx Type II DM, my priorities would be to assess for Polyuria, polydipsia,
blurred vision, slow wound healing, and signs of inadequate circulation to the feet
2. What information would you need to obtain on assessment of each of these patients?
For the 84 y.o. pt with urosepsis, I would need to obtain information concerning the urinary
system by assessing issues such as frequency, urgency, nocturia, dysuria, polyuria, oliguria,
hesitancy, incontinence, and obtain history of urinary disease, kidney disease, kidney stones,
urinary tract infections or pain in the groin, suprapubic region, or low back.
For the 62 y.o. pt with CVA, I would need to obtain information of neurologic system by
assessing issues such as history of seizure disorder, stroke, blackout, weakness, tic, tremor,
paralysis, coordination problems, numbness, or tingling, memory disorder.
For the 77 y.o c/o weakness, I would need to obtain information concerning the musculoskeletal
system by assessing for issues such as deformity, limitation of motion, weakness, gait problems or
problems with coordination, limited range of motion.
For the 82 yo with GI bleeds, I would need to obtain information concerning the GI system by
assessing for ulcer formation, nausea, vomiting, black stools, and flatulence For the 44 y.o. with 3
days s/p colectomy, I would need to obtain baseline information such a pain levels, last bowel
movement, activity level, current medications, nausea, vomiting, rectal bleeding, and current
nursing orders
For the 88 y.o. with CHF, I would need to obtain information concerning the cardiac system by
assessing chest pain, palpitation, cyanosis, dyspnea when walking one flight of stairs, edema,
hypertension, or coronary artery disease
For the 57 y.o. with chronic pancreatitis, I would need to obtain information concerning the GI
system by assess family history, alcohol use, biliary tract disease, peptic ulcer disease,
hyperlipidemia, hypercalcemia, and labs
For the 68 y.o. newly dx Type II DM, I would need to obtain information concerning diet,
exercise, kidney function, urine specific gravity, and glucose monitoring
3. What medications (classifications) do you anticipate finding on each patients MAR?
For the 84 y.o. pt with urosepsis the medication classifications that I would anticipate finding on
the MAR are: Urinary Tract Antiseptics (Cinoxacin, Methenamine, Nalidixic acid, Nitrofurantion),
Fluoroquinolones (Ciprofloxacin, Enoxacin, Gemifloxacin, Levofloxacin, etc), Sulfonamides
(Sulfadiazine, sulfamethizole, Sulfamethoxazole, etc
For the 62 y.o. pt with CVA, the medication classifications that I would anticipate finding on the
MAR are: Anticoagulant (heparin) Antiplatelet (Aspirin), Thrombolytics (plasmingogen
activator), Osmotic Diuretics (mannitol) or Diurectics (Lasix).
For the 77 y.o. pt c/o weakness, I would not anticipate finding medication classifications on the
MAR, but I would anticipate finding nursing orders that say: increase fluids, cluster activities ( for
rest), active range of motion exercises, and eating balance meals/or liquid nutritional supplements
For the 82 y.o. with GI bleeds, the medication classifications that I would anticipate finding on the
MAR are: H2-receptor antagonist (Cimetidine, Famotidine, Nizatidine, Ranitidine), Proton Pump
Inhibitors (Esomeprazole, Lansorprazole, Omeprazole, etc), and mucosal barrier protectants
For the 44 y.o. with 3 days s/p colectomy, the medication classifications that I would anticipate
finding on the MAR are: opioid analgesics, antibiotics/anti-infective to help decrease bowel flora
and reduce infection, stool softeners or laxatives, H2-receptor antagonist, Proton Pump Inhibitors
For the 88 y.o. with CHF, the medication classifications that I would anticipate finding on the
MAR are: ACE inhibitors, Angiotensin II receptor blockers, Diuretics, Digoxin, Vasodilators, or
Morphine
For the 57 y.o. with chronic pancreatitis, the medication classifications that I would anticipate
finding on the MAR are: Pancreatic Enzyme Replacements, Insulin/hypoglycemic medications
For the 68 y.o. newly dx Type II DM, the medication classifications that I would anticipate finding
on the MAR are: oral antidiabetic meds, or Insulin therapy
Decide what information you will want to have prior to calling the doctor…what will you want to assess prior
to making the call and be sure to think SBAR.
62 year old patient with a CVA: right hemiparesis; Dr. C.T. Scanner
0010
You finally get in to see this patient and you have difficulty arousing her. She barely arouses to
painful stimuli. You notice that she has minimal movement of all extremities and her vocalizations
are unintelligible. Her midnight vitals were BP 210/122, HR 88, RR 12 and Temp of 36.8°
S- Dr. Scanner, this is Aneva Taylor, Student nurse on neuro unit. I am calling you about a 62 y.o.
pt with a decrease level of conscious. I have difficulty arousing her. She barely arouses to painful
stimuli, has decrease movement, and her vocalizations are unintelligible.
B- A 62 y.o. female patient who presents with a CVA right hemiparesis.
A- Most recent VS: BP 210/122, HR 88, RR 12 and Temp of 36.8°
R- The pt could benefit from an emergency team STAT for her decrease conscious level and a
follow up to reassess her neurological status.
77 year old patient with c/o weakness; Dr. Ima Guessin
0100
This patient is complaining of not being able to get to sleep. He states that he usually takes
something at home every night to help him sleep. He wants you to call the doctor and get
something for him.
S- Dr. Guessin, this is Aneva Taylor, Student nurse on the Med Surg unit. I am calling about a 77
y.o. pt that is complaining of not being able to get to sleep.
B- A 77 y.o. pt with c/o weakness, and not being able to get to sleep.
A-The pt is unable to get to sleep.
R- The pt could benefit from a sleep aid to help improve his rest and a follow up to reassess his
medication treatments
84 year old confused patient with urosepsis; Dr. C. M. Pea
0210
Aide comes to tell you that the patient is very confused, trying to get out of bed…”was a little
confused at the beginning of the shift but nothing like this”. The patient is now screaming that
people are ‘trying to kill him’ and waking up all the other patients on the unit. You need to notify
the doctor of this change…what are you going to tell him/her? Unable to get vital signs or
assessment at this time.
S- Dr. Pea, this is Aneva Taylor, Student nurse on the Med Surg unit. I am calling about a 84 y.o.
pt very confused, and is trying to get out of bed. The situation has worsened since the beginning of
the shift and, currently, the pt is now screaming that people are “trying to kill him” and waking up
all the other pt’s on the unit.
B- A 84 y.o. confused pt admitted with urosepsis who condition has worsen since the beginning of
the shift
A-The pt is confused and currently showing signs of delusions
R- The pt could benefit from a neurological exam and follow up for a psych evaluation as well
88 year old patient with CHF; Dr. Dryem
0245
The patient calls you in to tell you that she is having difficulty ‘getting enough air’. You notice
that her respirations are much more labored and wet sounding than your earlier assessment.
S- Dr. Dryem, this is Aneva Taylor, Student nurse on the Med Surg unit. I am calling you about an
88 y.o. pt that is having difficulty getting enough air.
Also, I notice that her respirations are much more labored and wet sounding than my earlier
assessment
B- A 88 y.o. pt admitted with CHF
A-The pt currently displays wet sounding and labored respirations
R- The pt could benefit from respiratory therapy and reevaluation for medications treatment as
well
82 year old patient with GI bleed; Dr. Butts
0330
The aide tells you that she just got this patient back to bed after needing to use the bathroom. The
patient was weak and shaky on the way back to bed, stating he thought he was going to pass out.
Now feels better after lying down. His vitals were stable at midnight.
S- Dr. Butts, this is Aneva Taylor, Student nurse on the GI unit. I am calling you about an 82 y.o.
pt that needed to use the bathroom and on the way back to bed, the pt was weak and shaky and
stated that he thought he was going to pass out. But he said that he feels better after lying down
B- 82 y.o. pt admitted with GI bleed
A- The pt vitals were stable at midnight
R- The pt could benefit from more lab work and an evaluation for a colonoscopy
44 year old patient 3 days s/p colectomy; Dr. Kuttem
0400
The aide comes to tell you that the patient’s vital signs are really different than when she took
them at midnight. The temperature is now 103.8 with a pulse of 126.
S- Dr. Kuttem, this is Aneva Taylor, Student nurse on the GI unit. I am calling you about a 44 y.o.
pt whose temp is now 103.8 with a pulse of 126
B- 44 y.o. pt 3 days s/p colectomy, Temp. 103.8 with a pulse of 126
A- The pt’s’ temp is now 103.8 and pulse of 126 since midnight
R- This pt could benefit from blood cultures, and an infectious team evaluation
57 year old patient with chronic pancreatitis; Dr. Paenfle
0430
The aide comes to tell you that your patient is getting dressed in the room and says he is ‘going
home’ because he can’t get enough pain relief here. You are unable to give more pain medication
at this time. The patient wants to sign out AMA unless something is done.
S- Dr. Peanfle, this is Aneva Taylor, Student nurse on the GI unit. I am calling you about a 57 y.o.
who is experiencing pain and says that he wants to sign out AMA unless he gets more pain relief
B- 57 y.o. pt admitted with chronic pancreatitis. Patient is currently experiencing severe pain
A- pt states that he can’t get enough pain relief
R- This pt could benefit from reevaluation for pain medications
68 year old patient with newly diagnosed Type II DM; Dr. Sweeten
0545
The aide comes to tell you that the patient’s CBG is 408 and the patient is really sleepy. You have
an order for sliding scale insulin coverage but the order says to notify the MD for any blood
glucose > 400.
S- Dr. Sweeten, this is Aneva Taylor, Student nurse on the Med Surg unit. I am calling you about
a 68 y.o. pt with a CBG of 408. The order says to notify the MD for any blood glucose > 400
B- 68 y.o. pt admitted with newly diagnosed Type II DM. The pt’s glucose level are currently >
400
A- The pt is really sleepy and blood glucose 408
R- The pt could benefit from a an increase in diabetic medication and a diabetic consultation as
well