Prioritizing Care & Responding to Issues with A, B, C

This set of flashcards covers key concepts related to prioritizing nursing care, including definitions of primary and secondary goals, categories of urgency, signs of health alterations, and practical interventions.

Primary Goals of Nursing Care

Focus on safety for nurses/staff and clients as well as effective care that meets client’s needs.

Secondary Goals of Care

Efficient use of nurse's time and energy.

A-Urgent Priority Category

Issues that need immediate attention; the highest level of danger for death or severe injury.

B-Timely but not urgent

Actions that need to be completed in a timely manner but are not immediately life-threatening.

C-When able Priority Category

Actions that can usually wait, to be addressed when there is time.

Signs of Airway Obstruction

Nasal flaring, use of accessory muscles, skin cyanosis, and gasping for air.

Signs of Breathing Problems

Fast/slow breathing, increased work of breathing, and abnormal breath sounds.

Signs of Circulation Problems

Cyanosis, mottling, pallor, and abnormal capillary refill.

Prioritization Considerations

Focus on nurse and staff safety first, then client safety.

Effective Organization Tools

Worksheets, brain sheets, and report sheets that aid in organization and prioritization.

Recognizing Distress in Clients

Identifying cues that indicate a patient is in distress or immediate danger.

Take Action for Non-patent Airway

Remove/treat the cause of obstruction, open the airway or consider advanced interventions like intubation.

Assessing Breathing

Looking for signs of respiratory distress and listening for abnormal breath sounds.

Causes of Breathing Issues

Muscle weakness, CNS depression, trauma, and lung disorders.

Taking Action for Circulation Problems

Consider IV fluids, positioning, medications, and potentially cardiac compressions.

When to Call for Help

Recognizing the need for assistance and determining the level of help required.

NCLEX Priority Assessment

Identifying which patient should be assessed first based on urgency and need.