Which of the following demonstrate a nurse writing an expected outcome in measurable terms?

Priority setting is the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions (Hendry and Walker, 2004). In other words, as you care for a patient or a group of patients, you must deal with certain aspects of care before others. By ranking a patient’s nursing diagnoses in order of importance, you attend to each patient’s most important needs and better organize ongoing care activities. Priorities help you to anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems. Together with your patients, you select mutually agreed-on priorities based on the urgency of the problems, the patient’s safety and desires, the nature of the treatment indicated, and the relationship among the diagnoses. Establishing priorities is not a matter of numbering the nursing diagnoses on the basis of severity or physiological importance. Nurses establish priorities in relation to clinical importance, but they also prioritize on the basis of time. On a given day the demands that exist within a health care setting require you to ration your time wisely.

Classify a patient’s priorities as high, intermediate, or low importance. Nursing diagnoses that, if untreated, result in harm to a patient or others (e.g., those related to airway status, circulation, safety, and pain) have the highest priorities. One way to consider diagnoses of high priority is to consider Maslow’s hierarchy of needs (see Chapter 6). For example, risk for other-directed violence, impaired gas exchange, and decreased cardiac output are examples of high-priority nursing diagnoses that drive the priorities of safety, adequate oxygenation, and adequate circulation. However, it is always important to consider each patient’s unique situation. High priorities are sometimes both physiological and psychological and may address other basic human needs. Avoid classifying only physiological nursing diagnoses as high priority. Consider Mr. Jacobs’ case. Among his nursing diagnoses, acute pain and anxiety are of the highest priority. Tonya knows that she needs to relieve Mr. Jacobs’ acute pain and lessen his anxiety so he will be responsive to discharge education and be able to participate in postoperative care activities.

Intermediate priority nursing diagnoses involve nonemergent, nonlife-threatening needs of patients. In Mr. Jacobs’ case, deficient knowledge and impaired physical mobility are both intermediate diagnoses. It is important for Mr. and Mrs. Jacobs’ to understand potential problems that develop following surgery, know how to recognize the problems, and be able to continue appropriate care at home. Focused and individualized instruction from all members of the health care team is necessary throughout a patient’s hospitalization. The diagnosis of impaired physical mobility is not life threatening and will likely resolve once Tonya and the other nurses collaborate with the surgeon to ensure effective pain control. Relief of pain will make Mr. Jacobs’ more mobile and more active in his road to recovery.

Low-priority nursing diagnoses are not always directly related to a specific illness or prognosis but affect the patient’s future well-being. Many low-priority diagnoses focus on the patient’s long-term health care needs. Tonya has not yet identified a nursing diagnosis related to Mr. Jacobs’ concern about his sexual function. At this point the patient’s anxiety over the uncertainty of the success of surgery, the risk of cancer recurrence, and his concern about his sexual function are the predominant problems. If the patient learns from the surgeon that the procedure resulted in damage to the nerves affecting his sexual performance, a diagnosis more pertinent to this health problem is appropriate.

The order of priorities changes as a patient’s condition changes, sometimes within a matter of minutes. Each time you begin a sequence of care such as at the beginning of a hospital shift or a patient’s clinic visit, it is important to reorder priorities. For example, when Tonya first met Mr. Jacobs, his acute pain was rated at a 7, and it was apparent that the administration of an analgesic was more a priority than trying to reposition or use other nonpharmacological approaches (e.g., relaxation or distraction). Later, after receiving the analgesic, Mr. Jacobs’ pain lessened to a level of 4; and Tonya was able to gather more assessment information and begin to focus on his problem of deficient knowledge. Ongoing patient assessment is critical to determine the status of your patient’s nursing diagnoses. The appropriate ordering of priorities ensures that you meet a patient’s needs in a timely and effective way.

Priority setting begins at a holistic level when you identify and prioritize a patient’s main diagnoses or problems (Hendry and Walker, 2004). However, you also need to prioritize the specific interventions or strategies that you will use to help a patient achieve desired goals and outcomes. For example, as Tonya considers the high-priority diagnosis of acute pain for Mr. Jacobs, she decides during each encounter which intervention to do first among these options: administering an analgesic, repositioning, and teaching relaxation exercises. Critical thinking helps her to prioritize. Tonya knows that a certain degree of pain relief is necessary before a patient can participate in relaxation exercises. When she is in the patient’s room, she might decide to turn and reposition Mr. Jacobs first and then prepare the analgesic. However, if Mr. Jacobs expresses that pain is a high level and is too uncomfortable to turn, Tonya chooses obtaining and administering the analgesic as her first priority. Later, with Mr. Jacobs’ pain more under control, she considers whether relaxation is appropriate.

Involve patients in priority setting whenever possible. Patient-centered care requires you to know a patient’s preferences, values, and expressed needs. Tonya must learn what Mr. Jacobs expects with regard to pain control to have a relevant plan of care in place. In some situations a patient assigns priorities different from those you select. Resolve any conflicting values concerning health care needs and treatments with open communication, informing the patient of all options and consequences. Consulting with and knowing the patient’s concerns do not relieve you of the responsibility to act in a patient’s best interests. Always assign priorities on the basis of good nursing judgment.

Ethical care is a part of priority setting. When ethical issues make priorities less clear, it is important to have open dialogue with the patient, the family, and other health care providers (Holmstrom and Hoglund, 2007). For example, when you care for a patient nearing death or one newly diagnosed with a chronic long-term disabling disease, you need to be able to discuss the situation fully with the patient, know his or her expectations, know your own professional responsibility in protecting the patient from harm, know the physician’s therapeutic or palliative goals, and then form a plan of care. Chapter 22 outlines strategies for choosing a course of action when facing an ethical dilemma.