On every priority question that you get ask yourself if the patient fits into any of the following: I. ABC's
3. Circulation II. Maslow's hierarchy of needs
(physiological needs before psychological
1. Physiological or survival needs
2. Security needs (safety-protection from harm)
3. Belonging needs
4. Esteem needs
5. Self-actualization III. OREM theory of Nursing (AWFERSH)
ir (O2, H2o, temperature)
ater (dehydration, fluid volume excess
ood (malnutrition, feeding concerns)
limination (bowel & bladder problems, know expect I&O's of patient)
est (sleep, comfort, pain)
ocialization (right balance of solitude and social interactions)
azards (safety must be provided) IV. Assessment vs Implementation
1. Assessment - Do I have all the information I need? If not, assess FIRST!
2. Implementation - Is the patient in a critical state or needs immediate care? If so, implement right away! V.
Determine whether the question is asking for you to pick the EXPECTED or UNEXPECTED outcome.
1. Expected - is this suppose to happen to the patient? (i.e., side effect of med, disease process, lab values)
2. Unexpected - this is not suppose to happen. (adverse reaction, deterioration, etc) VI. Triage
1. chest wounds, airway obstruction, facial or chest burns, shock, pneumothorax, hemorrhage, etc
a. pt may exhibit anxiety, apprehension, restlessness, confusion, change in LOC... some early signs of hypoxia & ICP
2. abdominal wounds w/o hemorrhage, GI and CNS injuries, etc
3. fractures, burns, lacerations, etc
4. usually people that cant be saved, absent pulses, absent bp, fixed and dilated pupils.
Hence, "1,2,3" is for who you would see first in that category.
Hope this helps!