Guidelines for Prioritizing
- Airway, Breathing, Circulation (ABCs)
- MAA-U-AR
- Mental Status Change
- Acute Pain
- Acute Urinary Elimination Problems
- Untreated Medical Problems
- Abnormal Laboratory Values
- Risk of Infection, Safety or Security
- Long-Term Treatments
Triage
- Simple Triage And Rapid Treatment (START)
- Red: Immediate (Critical)
- Yellow: Delayed (Urgent)
- Green: Minor (Ambulatory)
- Black: Deceased (Expired)
- Ability to Walk
- Spontaneous Breathing
- Respiratory Rate
- Check Circulation
- Mental Status
How to Use Prioritization in Exam Questions
- Airway
- Breathing
- Circulation
- Change in LOC (Altered Mental Status)
- Sepsis
- Acute Pain
- Untreated Medical Problems
- Education
- Feelings
- Patient Waiting to be Discharged
- Maslow’s Hierarchy of Needs
Airway, Breathing, Circulation (ABC's)
- Changed Sound of Voice
- "See-saw" Respirations
- Stridor
- Normal Respiratory Rate: 12–20 Breaths/Min
- Use of Accessory Muscles in Respiration
- Cyanosis
- Color of Hands and Digits
- Normal Capillary Refill Time (CRT): 2 Seconds
- Decreased LOC
- Initial ‘Look, Listen and Feel” Assessment
- Emergency Treatment
- Prioritization in Exam Questions
The Nursing Process
- ADPIE
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
How to Use ADPIE for Exam Questions
- Data Collection
- Data Analysis
- Plan of Care
- Action or Intervening
- Outcomes of Care
- Read Entire Question
- Identify Step in the Nursing Process
- Eliminate Answer Choices; Choose the Best Answer
Strategic Words
- First/Initial/Early
- Highest Priority
- Most Appropriate
- Assess
- Collect/Gather
- Identify
- Action/Intervention
- Normally/Generally
- Always/Never/None
Maslow's Hierarchy of Needs
- Oxygen, Water, Nutrition
- Body temperature, Elimination, Shelter, Sexual Expression
- Physical Safety
- Physiological Safety
- Affection and Companionship
- Self Respect and Respect for Others
- Fulfillment
Safety and Security
- Second Basic Needs
- Physical Safety
- Physiological Safety
- Financial Security
Love and Belonging
- Third Basic Need
- Love and Affection
- Relationships
Esteem
- Fourth Basic Need
- Esteem for Oneself
- Reputation and Respect
Self-Actualization
- Fifth Need
- Helping Others
- Objectivity
- Personal Growth
Cardiopulmonary Resuscitation (CPR) for Adults
- Scan Scene
- Activate Emergency Response System
- Check For Breathing (Max 10 Seconds)
- Open Airway
- Compressions: 2 Inches Deep (100-120 Compressions/Min)
- Airway: Ensure Airway is Still Open
- Breathing: Administer 2 Rescue Breaths
- Repeat C-A-B Sequence (30:2) Until Help Arrives