Management of Care – Prioritization & Delegation

Lecture Context

Original plan: cover chest tubes, but topic postponed due to time (only ≈ 30 min today, maybe ≈ 40 min tomorrow).
Chose “Management of Care” (prioritization & delegation) instead—considered “fluffy” compared with high-risk skills (e.g., chest tubes).
Goal: keep session light yet practical; intensive content (infection, chest tubes, etc.) will resume next week.
No PowerPoint; learning will rely on discussion + upcoming activity that doubles as a study guide.
Exam info: 39 questions will stem from infection content (appendicitis, peri-op, etc.). Templates for those units will be provided next week because students find them helpful.

Prioritization Fundamentals

Definition: Selecting which patient to see or which task to perform first, second, third, etc.
Applies to typical Med-Surg load (5–7 patients).
Decision-making occurs continuously (dynamic, not a one-time list made at shift start).
Requires:
- Critical thinking (develops with experience).
- Constant reassessment of cues (vital-sign trends, lab values, patient reports).

Key Outcome

Proper prioritization ➜ better patient outcomes, safety, time management, and supports clinical judgment.

Common Frameworks for Setting Priorities

ABCs: Airway, Breathing, Circulation.
- Example: Bleeding vs. airway obstruction—determine which is imminent/solvable first.
Stable vs. Unstable: See unstable patients first.
Maslow’s Hierarchy: Physiological → Safety → Love/Belonging → Esteem → Self-actualization.
CURE model (introduced in “Cognitive Stacking” article):
- Critical – life-threatening.
- Urgent – could become critical quickly.
- Routine – standard, scheduled care.
- Extra – comfort measures, non-essential tasks.

Recognizing Life-Threatening Cues

Hemorrhage.
Cerebral edema (HA, neuro changes).
Severe hypotension (SBP in $80\text{s}$ ).
Any airway compromise.

Delegation Essentials

Definition: Transfer of a task to another team member while retaining accountability for the outcome.
Analogy: Passing the baton in a relay—team wins/loses together.

“EAT” Rule – Never Delegate:

Evaluate
Assess (initial)
Teach (initial)

Appropriate Patients for Delegation

Must be stable with expected outcomes.
Avoid new admissions or anyone with a change in condition.

Five Rights of Delegation

Mnemonic: “Terrific Care Promotes Client Safety”

Right Task – falls within the delegatee’s scope.
Right Circumstance – patient is stable; condition & complexity appropriate.
Right Person – delegatee possesses skill/training.
Right Communication – clear, specific instructions: what, when, how to report, parameters requiring immediate report.
Right Supervision/Evaluation – RN monitors, gives feedback, and is answerable for results.

Example of clear communication:
“Please ambulate Mr. Smith 50 ft with a gait belt now. If he reports dizziness or SpO₂ < $92\%$ , return him to bed and notify me immediately.”

Scope of Practice Snapshot (NC Board of Nursing references)

CNA I: Basic ADLs—bed baths, linens, ambulation, routine VS.
CNA II (additional):
- Remove peripheral IVs.
- Flush tubing, monitor (not adjust) IV flow rates.
- Insert Foleys if outcome predictable (e.g., male w/out enlarged prostate).
UAP (varies): May collect blood, remove IVs if trained.
LPN:
- Takes stable patients.
- May insert peripheral IV, hang IV fluids/selected meds, administer blood if facility permits.
- Can reinforce teaching & perform re-assessments, but cannot create care plans.
RN: Full assessment, initial teaching, care-plan formulation, IV push meds, evaluation, critical decision-making, delegation oversight.

Facilities may restrict but never expand scope beyond state board allowances.

Pre-Delegation Checklist

Assess patient stability.
Determine task complexity & step count.
Confirm outcome is predictable.
Select delegatee whose competency matches.
Provide explicit instructions (parameters, timing, documentation requirements).
Plan follow-up / supervision.

Non-Delegable Nursing Functions

Initial assessment & admission history.
Formulating or revising care plans.
Patient education requiring judgment (new diagnoses, new meds).
Nursing judgment/critical decisions.
Evaluation of care effectiveness.

Prioritization & Delegation Exercise – Mr. Smith (CHF)

Patient Data:

65 y/o male, Dx: Congestive Heart Failure.
Hx: HTN, DM II, CKD.
S/S: Dyspnea on exertion, 2⁺ pedal edema, fatigue.
On O₂ via NC.

Active Orders & Recommended Actions

Order	Priority?	Delegate?	Rationale
Vital signs q4h	High (do first)	CNA	Need baseline before meds affecting BP/HR (e.g., Lisinopril, Lasix).
Insert peripheral IV	High	LPN or RN	Necessary for IV Lasix & labs; pharmacy prep time considered.
Baseline labs (CMP, BNP, K⁺, etc.)	High	RN/LPN (draw with IV start)	Check electrolytes before diuretic.
Begin IV Lasix $40\,mg$	After labs, VS, IV	RN	Can cause hypotension & K⁺ loss.
Administer Lisinopril $10\,mg\;PO$	After VS	RN	Hold if HR < $60$ or SBP < $100$ .
Administer Metformin $500\,mg\;PO$	Medium	RN	Check blood glucose even though oral.
Apply continuous O₂ @ $2\,L/min$ & titrate to SpO₂ > $92\%$	Immediate	RN (initiation cannot be delegated)	Airway/Breathing priority.
Cardiac monitor hookup	Medium	Telemetry tech / CNA II	Detect dysrhythmias, esp. post-Lasix electrolyte shifts.
Strict I&O	Medium	CNA with RN supervision	Track diuresis & renal function.
Daily weight	Medium-Low	CNA	Fluid-status trend; many beds have integrated scales.
Progressive mobility	Low initial shift	CNA if stable	Delay until VS stable & dyspnea controlled.
Patient education (CHF, diet)	Low (can wait)	RN leads; LPN may reinforce	Not urgent during initial stabilization.
Cardiac diet order entry	Low	Unit clerk or RN	Dietary handles delivery.

Decision Rationale Illustrated

Stabilize airway/breathing: ensure O₂, monitor SpO₂.
Collect data needed to safely give meds (VS, labs).
Secure access (peripheral IV), then administer priority meds.
Delegate routine tasks (weights, I&O) once patient stable.
Education & mobility postponed until acute issues addressed.

Example Delegation Script (Per Five Rights)

“Maria (CNA II), within the next 15 min please obtain Mr. Smith’s full set of vitals. Record them in the EMR. If SBP < $100\,mmHg$ , HR < $60\,bpm$ , or SpO₂ < $92\%$ , notify me immediately before I administer his medications.”

Ethical & Practical Implications

RN remains legally & ethically accountable even after delegating.
Clear communication prevents errors akin to misreading med instructions (e.g., sliding-scale insulin variation).
Time management improved by matching task urgency to team capabilities.
Calling for help (charge nurse, Rapid Response) is essential when simultaneous crises (airway vs. hemorrhage) exceed a single nurse’s capacity.

Upcoming Learning Tools

“Cognitive Stacking” article—introduces CURE model; required reading to deepen prioritization strategy.
In-class activity tomorrow will solidify delegation/prioritization concepts; serves as study guide for exam.
Templates for infection unit (39 exam questions) will be uploaded next week.

Quick Numerical References (formatted per LaTeX)

Vital-sign medication parameters:
• Hold beta-blocker if HR < $60\,bpm$ or SBP < $100\,mmHg$ .
Typical Med-Surg assignment: $5\text{–}7$ patients.
Oxygen goal: SpO₂ > $92\%$ via NC $2\,L/min$ .
Lasix dose example: $40\,mg$ IV.
Exam breakdown: $39$ questions from infection content.

Study Tips

Memorize Five Rights of Delegation & “EAT” rule.
Practice ABC/CURE decision trees on sample cases.
Review NC Board of Nursing scope documents for CNA I, CNA II, LPN, RN.
Drill vitals-based med-holding parameters.
Remember: dynamic reassessment—priorities shift as patient data change.