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Prioritizing in Life and on the NCLEX

I spent a little time enjoying the holidays, visiting family, and resting. I hope you got a bit of a study break as well as they say, "all work and no play...makes us dull". Caregiver role strain is going to be an issue no matter what type of nursing job you take on and I am sure you just got through a stressful time at school. Nurses are caregivers - to our patients, our families, and our friends.

Some signs of "caregiver role strain" are when you seem more tired than usual, less interested in hobbies or fun, and seem to lose that spark that you typically have. Essentially every symptom of mild depression. Taking care of others takes a lot of energy. Here are a couple of tips to keep you going and accomplish all those New Year's Resolutions!

• eat healthily don't revert to junk food because it's easy
• exercise daily will help get out stress
• know your limits and don't be afraid to say no
• ask for help
• write 3 things you want to accomplish each day and do them
• look at the positive and be thankful
• have an outlet to express your feelings through art, journaling, talking, or music
• get sleep
• continue to find time to do things you enjoy
• take breaks/vacations even if it is just a day here and there to getaway

When I think about the new year - I always look forward to the things I want to accomplish. However, prioritizing what I want to accomplish most is essential. Being able to rank tasks in order of importance is certain to be on the NCLEX and essential to safe patient care and career success. Here are some concepts to know like the back of your hand.

The ABCs

Please always remember airway, breathing, and circulation. These are written in order of importance from most to least. If you are faced with a situation or test question - look for the "best answer" which will be the appropriate priority.

For example,

A nurse has just finished receiving morning report. He has four patients on a medical-surgical unit. Which patient should he assess first?

A. The diabetic patient with a leg wound. This patient has intravenous antibiotics due at 0900. His vitals are BP 130/80, HR 77, RR 22, Temp 98.7, Pulse ox 98%/RA, Glucose 128.

B. The patient was admitted from the Emergency Department last night in status asthmaticus. She has intravenous prednisone due at 0800. Her vitals are BP 133/77, HR 90, RR 50, Temp 99.8, Pulse ox 90%/RA.

C. The dialysis patient has daily medications due at 0800. He is going to dialysis today and his vitals are BP 160/60, HR 88, RR 20, Temp 98.6, Pulse ox 95%/RA.

D. The patient admitted for delirium tremens received 1 mg Ativan IV PRN from the off-going nurse. He is currently sleeping and his vitals are BP 125/77, HR 90, RR 21, Temp 98.8, Pulse ox 98%/RA.

Answer: B. Airway is the main priority. The patient breathing at a rate of 50 respirations per minute and with oxygen saturation of 90% may be in respiratory distress. The normal values for respiratory rate (RR) and oxygen saturation are 16RR, and 92%. Answer C., also has aberrant vitals - an elevated blood pressure. The airway is prioritized over circulatory system abnormalities. You would want to care and stabilize the airway issue before treating the blood pressure. The asthma patient probably needs an albuterol treatment, a respiratory therapist, the dose of prednisone and perhaps oxygen, and a transfer to ICU if that does not stabilize her. The patient in C has elevated blood pressure, but medications are typically held before dialysis and his dialysis treatment will treat the blood pressure.

Maslow's Hierarchy of Needs

Maslow's Hierarchy of Needs is often pictured as a pyramid by which different levels of needs are written. The basic concept is that we as humans tend to address needs at the foundational, bottom levels of the pyramid before we can "self-actualize" and address needs towards the top.

From bottom to top (in the order we address them), the levels are the following:

1. Physiological: eg - breathing, food, water, sex
2. Safety: eg - employment, health, property, morality
3. Love and Belonging: eg - friendship, family, intimacy
4. Esteem: eg - self-esteem, confidence, respect
5. Self-actualization: eg - morality, creativity, spontaneity

In nursing, we can apply this to understanding the priorities of our patients and how they will address issues. Patients will tackle priorities that are physiological before those that are esteem for example. These are the choices you should make in your questions as well.

For example -

A nurse is reviewing the nursing plan of care for a pregnant client with a diagnosis of asthma. What nursing diagnosis should be the highest priority for this client?

1. Activity intolerance
2. Ineffective breathing pattern
3. Disturbed body image
4. Anxiety

Answer: 2

1. Note the keywords highest priority. Use Maslow's hierarchy of needs to prioritize, remembering that physiological needs comes first. Using this guideline will direct you to option 2. Breathing is a physiological need and is the priority nursing diagnosis.