Time Management Tools Chapter 18 of Nursing Leadership and Management Introduction Time Management Time management is “a set of related common-sense skills that helps you use your time in the most effective and productive way possible” (Kelly, p. 427). Importance Time management is important for nurses on the job and nurses in their daily lives. Time management facilitates the prioritization of care, deciding on appropriate outcomes and the performance of the most important interventions first. Overview The Pareto Principle ABC Maslow’ Hierarchy End of Shift Reports Shift Action Plan Triangle Hierarchy Prioritization and Delegation Exercise The Pareto Principle “is a strategy for balancing life and work through prioritization of effort” (Kelly, 427). "Lose an hour in the morning and you will be all day hunting for it" Richard Watley (1864) The Pareto Principle “States that 20% of focused efforts results in 80% of outcome results, or conversely that 80% of unfocused efforts result in 20% of outcome results” p. 427. Example: Reading textbooks while logged into Facebook vs. reading textbooks and focusing on what you are reading. Planning your time leads to more productivity. When you are frenzied and unorganized, you will be less productive. Example: gathering items for a task like a wound change. If you are going back and forth from the supply room, you waste time. If you gather your supplies before you start, you will save time. If you can achieve more with focused effort why don’t more people do so? • They might not know how. • They might enjoy the attention. • They believe they are so busy they do not have time to plan. • They love the state of crisis. Incorporating the Pareto Principle into Practice Establish objectives Prioritize Eliminate tasks-delegate Plan your time! Work smarter, rather than making work harder! McLauchlan, C. (1997). Time Management. Journal of Emergency Medicine, 14(5), 345-346 Conclusion The Pareto Principle can be applied to many situations at work and in daily life. There are times when you would want to use different strategies, especially in a life threatening condition. ABC’s of Prioritizationa guide to determining life-threatening conditions A- Airway B- Breathing C- Circulation First priority: Life-threatening or potentially life-threatening conditions Vital signs or level of consciousness have potential for respiratory or circulatory collapse Risk to themselves or others Can occur at any time during a shift Not always able to anticipate Need to monitor at risk patients to prevent adverse reactions Secondary priority: limb-threatening and sightthreatening ABC’s to determine lifethreatening Airway Is it patent and open? Any obstructions or foreign body? Need for artificial for artificial airway To maximize opening of airway Jaw-thrust Chin-lift maneuver (suspected head or neck trauma) ABC’s continued Breathing Adequate respirations? Rate, rhythm, depth, chest rise, and work of breathing Advantageous or absent breath sounds Pulse oximetry Use of accessory muscles, retractions or seesaw pattern Provide ventilation Inadequate respirations ABC’s lastly Circulation Pulse Slow, irregular, weak or rapid Bounding and full Blood pressure Skin color and temperature High vs. low Warms and dry vs. cool and clammy Possibility of hemorrhage internal or external General Appearance, & LOC Level of Consciousness Is the pt alert and oriented? Confused? Unresponsive? Glasgow Coma Score can be used to determine the LOC General appearance- How does the patient look and act? Table 18-2 Top Priority with Potential Threats to Their ABC’s Respiratory Cardiovascular Airway compromise Choking Asthma Chest trauma Cardiac arrest Shock Hemorrhage Neurological Major head trauma Unconscious/ Unresponsive Seizures Other Major trauma Major amputation Major burn especially involving airway Abdominal trauma Vaginal bleeding Anaphylaxis Diabetic with altered LOC Septic Shock Child or Elder Abuse Activity Scenario 1 You are a nurse who has stopped at the scene of a motor vehicle crash. You are first on the scene. As the ambulances begin to arrive you direct which patients need to be transported in which order. Scenario 2 You are on duty at a small community hospital early one morning when receive reports of a construction accident a mile away. You call the physician on call and then prepare to receive the patients. Three ambulances arrive simultaneously with 5 patients. Gurney, D. (2004). Exercise in Critical thinking at triage: prioritizing patients with similar acuities. Journal of Emergency Nursing, 30(5), 514-515. DOI: 10.1016/j.jen.2004.07.005 Maslow’s Hierarchy Page 20-21 SelfActualization Morality, creativity Esteem Needs Self esteem, confidence, achievement Social Needs/Love and Belonging Interaction with others, friendships Safety Needs Safety of the body, family, health Safe working conditions, job security, benefits Physiological Needs Breathing, food, water, excretion Breaks, adequate salary, working conditions Spend your time according to your needs, or your patients needs. A Nursing Team Leader Caring for Multiple Clients You are the team leader providing care for six clients. The team includes yourself (RN), an LVP, and a newly hired nursing assistant. Mr. C, 68 y/o M with unstable angina who needs teaching for a cardiac catheterization scheduled this morning. Ms. J, a 45 y/o F experiencing chest pain scheduled for a graded exercise test later today. Mr. R., a 75 y/o M with a 4day-old left sided stroke Ms. S. an 83 y/o woman with heart disease, a history of MI, and mild dementia. Ms. B, a 93 y/o F, newly admitted from long-term care with decreased UO, ALOC and an elevated temperature of 99.5F Mr. L, a 59 y/o man with mild SOB and chronic emphysema 1. 2. Which clients should you assign to the LVN? Which client should you assess first? 1. 2. 3. 4. Mr. C Ms. J Ms. B Mr. L Mr. C, 68 y/o M with unstable angina who needs teaching for a cardiac catheterization scheduled this morning. Ms. J, a 45 y/o F experiencing chest pain scheduled for a graded exercise test later today. Mr. R., a 75 y/o M with a 4day-old left sided stroke Ms. S. an 83 y/o woman with heart disease, a history of MI, and mild dementia. Ms. B, a 93 y/o F, newly admitted from long-term care with decreased UO, ALOC and an elevated temperature of 99.5F Mr. L, a 59 y/o man with mild SOB and chronic emphysema 1. 2. 3. 4. Which of the following tasks should you delegate to the nursing assistant? Ask Ms. S memorytesting questions. Tell Ms. J about treadmill exercise testing. Check pulse oximetry for Mr. L. Monitor urine output for Ms. B. 1. 2. 3. 4. Close to the end of the shift, the LVN reports that the nursing assistant has not totaled clients’ intake and output for the past 8 hours. What is your best action? Confront the nursing assistant and instruct her to complete this assignment. Delegate this task to the LVN as the nursing assistant may not have been educated in this task. Ask the nursing assistant if she needs assistance in completing the intake and output records. Notify the nurse manager to include this on the nursing assistant’s evaluation. Shortness of breath, Edema, and Decreased Urine Output Ms. J. is a 63 y/o F who is admitted directly to the medical unit after visiting her physician for SOB and increased swelling in her ankles and calves. Her admitting DX is rule out chronic renal failure (CRF). Ms. J states that her symptoms have become worse over the past two to three months and that she uses the bathroom less often and urinates in smaller amounts. Her past medical history includes HTN (30 years), CAD (18 years) and type 2 diabetes. Ms. J. is a 63 y/o F who is admitted directly to the medical unit after visiting her physician for SOB and increased swelling in her ankles and calves. Her admitting DX is rule out chronic renal failure (CRF). Ms. J states that her symptoms have become worse over the past two to three months and that she uses the bathroom less often and urinates in smaller amounts. Her past medical history includes HTN (30 years), CAD (18 years) and type 2 diabetes. Admission vital signs: Temp: 97.8 F BP: 162/96 HR: 88 RR: 28 Pulse ox: 91% on room air Admission lab tests to be collected on the unit include serum electrolytes, renal function tests, CBC and urinalysis. A 24 hour collection for creatinine clearance has also been ordered. You are the team leader, supervising an LVN. Which nursing care action for Ms. J should you delegate to the LVN? 1. Insert and intermittent catheter to assess for residual urine. 2. Plan fluid restriction amounts to be given with meals. 3. Check breath sounds for presence of increased crackles. 4. Discuss renal replacement therapies with the patient. As team leader, you observe the nursing assistant (NA) perform all of these actions for Ms. J. For which action must you intervene? 1. NA assists Ms. J to replace oxygen nasal cannula. 2. NA checks Ms. J.’s vital signs after the patient drinks fluids. 3. NA ambulates with Ms. J to the bathroom and back. 4. NA washes Ms. J’s back, legs, and feet with warm water. 1. 2. 3. 4. You are supervising a new orienting nurse providing care for Ms. J, who has had surgery to create a left forearm dialysis access. Which of the following actions performed by the nurse requires that you intervene? The nurse monitors the patient’s operative site dressing for evidence of bleeding. The nurse obtains BP reading by placing the cuff on the right arm. The nurse draws post-operative lab studies from temporary dialysis access. The nurse administers oxycodone by mouth for moderate post-operative pain. Assessment of Ms. J after dialysis reveals all of these findings. Which assessment finding necessitates immediate action? 1. Ms. J’s weight is decreased by 4.5 pounds 2. Ms. J’s systolic blood pressure is decreased by 14 mm Hg. 3. Ms. J’s level of consciousness is decreased. 4. Ms. J.’s temporary catheter dressing has a small blood spot. 1. 2. 3. 4. Six months later, Ms. J is readmitted to the unit. She has just returned from hemodialysis. Which nursing care action should you delegate to the nursing assistant? Obtain vital signs and post-dialysis weight. Assess hemodialysis access site for bruit and thrill. Check and assess site dressing for bleeding. Instruct patient to request assistance getting out of bed. Cardiovascular Problems 1. 2. 3. 4. You are the charge nurse for the coronary step down unit. Which patient is best to assign to an RN who has floated for the day from the general medical-surgical unit? Patient requiring discharge teaching about coronary artery stenting prior to going home with spouse today. Patient receiving IV furosemide (Lasix) to treat acute left ventricular failure. Patient just transferred from the radiology department after a coronary angioplasty. Patient just admitted with unstable angina and who has orders for a heparin infusion and aspirin. You are working in the ED caring for a patient who was just admitted with left anterior chest pain, possible unstable angina or myocardial infarction. Which nursing activity will you accomplish first? 1. Auscultate heart sounds. 2. Administer SL nitro. 3. Insert an IV catheter. 4. Obtain a brief patient health history. A patient with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells you, “I feel really dizzy.” Which action should you take first? 1. Help the patient to sit down. 2. Check the patient’s apical pulse. 3. Take the patient’s BP. 4. Have the patient breath deeply. A diagnosis of ventricular fibrillation is identified for an unresponsive 50-year-old patient who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 Joules 2. Start CPR 3. Administer Epi 1 Mg IV 4. Intubate and manually ventilate. You are ambulating a cardiac surgery patient who has telemetry cardiac monitoring when another staff member tells you that the patient has developed a supraventricular tachycardia with a rate of 146 beats per minute. In which order will you take these actions? 1. Call the patients physician. 2. Have the patient sit down. 3. Check the patients blood pressure. 4. Administer oxygen by nasal canula.