Question

Time Evaluation and Priority Setting Lisa Jones, 88 year old, was admitted to the unit from surgery yesterday, after having a cardiac catherization with PCI. Lisa's history includes chronic atrial flutter, urinary incontinence, and diabetes mellitus. During the night, she pulled her urinary catheter and IV catheter out. The night nurse reported to you that the IV catheter and Foley catheter would need to be replaced. The nurse explains that there was a cardiac emergency on the unit which has delayed the Foley and IV being replaced. The patient complaints that she has pain/discomfort in the rectum and is very upset at the night staff because they don't care about patient's and are rude. After she stops yelling and has calmed down, she informed you that she has pain in her left calf. During assessment, the nurse notes that the area is warm, reddened and tender to touch. Doctors Order: 1. Baseline Partial Thromboplastin time, International Normalized Ration, Platelet count, Hemoglobin and hematocrit 2. Repeat PTT per heparin protocol (every 6 hours at first) 3. Chest radiograph 4. Intravenous heparin per protocol 5. Elevate and apply heat to affected extremity Directions: 1. What are the focus areas of assessments? 2. Determine the priority after performing the assessment. 3. Use the Time log provided to plan your activities in order of priority

Answer 1

1. The focused area of assessment is

• Cardiac system to assess for normal rhythm
• Urinary incontinence
• Assess the catheter insertion site
• Assess the left leg for DVT
• Assess for vital signs
• Assess for a blood glucose level.

2. Priority in performing of assessment:

• Do blood test as per physician orders.
• Monitor vital signs.
• Assess the left leg for deep vein thrombosis and administer heparin.
• Assess the catheter insertion site for bleeding, oozing, and drainage.
• Monitor the cardiac rhythm.
• Assess urinary retention and insert a foley catheter.
• Monitor blood glucose level.

3. TIME LOG

Time	Activity	Duration	Notes
0700	Do PT, PTT, INR, platelet, Hb, HCT	6 min	follow report
07:06	Check vital signs	4 min	Record the findings.
07:10	Assess the Leg for warm, tender, and DVT	3 min	Record the observed findings.
07:15	Elevate the left leg and apply heat to the affected area.	10 min	Enter the pre and post-procedural data.
07:25	Insert new IV line and Administer heparin as per protocol	3 min	Document the dose of heparin
07.28	Check for blood sugar and administer medication if needed	2 min	Document the blood sugar level and medication given.
07:30	Assess the catheter insertion site for any bleeding or oozing.	2 min	Document the area
07:32	Assess urinary incontinence and insert foley's catheter.	10 min	Document the procedure and urine output.
07:45	Monitor ECG rhythm and Spo2	2 min	Document the observed rhythm and spo2 rate.
09:00	Arrange for chest radiograph		Follow the procedure and document.
01:30	Repeat PTT	2 min	Document the report.