CLINICAL REFERENCE GUIDE
Leadership, Delegation, & Community Health Nursing
1. Leadership & Prioritization: Priority Triage
In clinical environments, nurses utilize the Airway-Breathing-Circulation (ABC) framework as the primary
mechanism to rapidly assess and prioritize patient care. Life-threatening physiological disruptions always
supersede psychosocial or chronic pathologies. Below is a triage assessment of four complex patient charts
detailing the clinical rationale for prioritization.
Clinical Reference Guide: Leadership & Community Health 1
, Patient Presentation
Priority ABC Classification Clinical Rationale & Immediate Action
& Chart Details
1 Patient A: 45-year-old AIRWAY Immediate Risk: Stridor indicates acute partial
(Highest) male, post-operative upper airway obstruction, likely secondary to
thyroidectomy. laryngeal edema or hematoma formation post-
Demonstrates audible thyroidectomy.
stridor, intercostal Action: Secure the airway, call rapid response,
retractions, and prepare tracheostomy kit at bedside, administer
extreme agitation. humidified oxygen.
2 Patient B: 62-year-old BREATHING Immediate Risk: Severe hypoxemic respiratory
female, acute failure. While secondary to a chronic condition,
exacerbation of COPD. acute respiratory failure requires rapid
SpO₂ is 84% on 2L intervention before respiratory arrest occurs.
nasal cannula; using Action: Titrate oxygen carefully (consider
accessory muscles to Venturi mask or BiPAP), assess breath sounds,
breathe. administer prescribed bronchodilators.
3 Patient C: 29-year-old CIRCULATION Immediate Risk: Septic/hypovolemic shock.
male, admitted with a Hypotension and tachycardia indicate systemic
ruptured appendix. BP hypoperfusion.
88/50 mmHg, HR 124 Action: Establish dual large-bore IV access,
bpm, skin cool and initiate rapid fluid resuscitation (isotonic
clammy. crystalloids), collect blood cultures, and
administer broad-spectrum antibiotics.
4 Patient D: 78-year-old CHRONIC / INFECTION Immediate Risk: Localized infection with
female, history of type 2 systemic signs (fever), but hemodynamically
diabetes, presenting stable and completely patent airway/breathing
with an open, purulent status.
stage IV sacral Action: Perform wound care/dressing change,
pressure injury. Temp: administer scheduled antipyretics and targeted
38.1°C. antibiotics, monitor vitals for progression to
shock.
2. Delegation Frameworks: The E-A-T Rule
Safe delegation is a core competency for Registered Nurses (RNs) to optimize care outcomes. The E-A-T
Framework specifies that the core responsibilities of the RN cannot be delegated to Licensed Practical/
Vocational Nurses (LPNs/LVNs) or Unlicensed Assistive Personnel (UAPs/CNAs).
Clinical Reference Guide: Leadership & Community Health 2
Leadership, Delegation, & Community Health Nursing
1. Leadership & Prioritization: Priority Triage
In clinical environments, nurses utilize the Airway-Breathing-Circulation (ABC) framework as the primary
mechanism to rapidly assess and prioritize patient care. Life-threatening physiological disruptions always
supersede psychosocial or chronic pathologies. Below is a triage assessment of four complex patient charts
detailing the clinical rationale for prioritization.
Clinical Reference Guide: Leadership & Community Health 1
, Patient Presentation
Priority ABC Classification Clinical Rationale & Immediate Action
& Chart Details
1 Patient A: 45-year-old AIRWAY Immediate Risk: Stridor indicates acute partial
(Highest) male, post-operative upper airway obstruction, likely secondary to
thyroidectomy. laryngeal edema or hematoma formation post-
Demonstrates audible thyroidectomy.
stridor, intercostal Action: Secure the airway, call rapid response,
retractions, and prepare tracheostomy kit at bedside, administer
extreme agitation. humidified oxygen.
2 Patient B: 62-year-old BREATHING Immediate Risk: Severe hypoxemic respiratory
female, acute failure. While secondary to a chronic condition,
exacerbation of COPD. acute respiratory failure requires rapid
SpO₂ is 84% on 2L intervention before respiratory arrest occurs.
nasal cannula; using Action: Titrate oxygen carefully (consider
accessory muscles to Venturi mask or BiPAP), assess breath sounds,
breathe. administer prescribed bronchodilators.
3 Patient C: 29-year-old CIRCULATION Immediate Risk: Septic/hypovolemic shock.
male, admitted with a Hypotension and tachycardia indicate systemic
ruptured appendix. BP hypoperfusion.
88/50 mmHg, HR 124 Action: Establish dual large-bore IV access,
bpm, skin cool and initiate rapid fluid resuscitation (isotonic
clammy. crystalloids), collect blood cultures, and
administer broad-spectrum antibiotics.
4 Patient D: 78-year-old CHRONIC / INFECTION Immediate Risk: Localized infection with
female, history of type 2 systemic signs (fever), but hemodynamically
diabetes, presenting stable and completely patent airway/breathing
with an open, purulent status.
stage IV sacral Action: Perform wound care/dressing change,
pressure injury. Temp: administer scheduled antipyretics and targeted
38.1°C. antibiotics, monitor vitals for progression to
shock.
2. Delegation Frameworks: The E-A-T Rule
Safe delegation is a core competency for Registered Nurses (RNs) to optimize care outcomes. The E-A-T
Framework specifies that the core responsibilities of the RN cannot be delegated to Licensed Practical/
Vocational Nurses (LPNs/LVNs) or Unlicensed Assistive Personnel (UAPs/CNAs).
Clinical Reference Guide: Leadership & Community Health 2
