ATI Nurse Logic: Priority Setting Frameworks

Breathing

Second highest priority Essential for oxygen exchange: - Respiratory rate within expected reference range - Adequate ventilatory effort Client might need: - Artificial ventilation - Negative pressure gradient in pleural cavity Chest tube might re-establish negative pressure

Least Invasive Interventions

Incontinent clients on bladder routine Incentive spirometers/inhalation treatments Oral or rectal administration of medications.

1. Assessment 2. Diagnoses (Analysis) 3. Planning 4. Implementation 5. Evaluation

What are the 5 steps of the Nursing Process?

1. Maslow's Hierarchy of Needs 2. Nursing Process 3. ABC's 4. Safety and Risk Reduction 5. Least Restrictive/Least Invasive 6. Survival Potential 7. Acute/Urgent/Unstable VS. Chronic/non-urgent/stable findings

What are the 7 Priority Setting Frameworks?

Emergent

Class I - Life threatening injuries Immediate treatment= chance for survival Highest priority

Urgent

Class II - serious and extensive injuries Do not pose immediate threat to life Potential for survival even with delayed treatment

Nonurgent

Class III - less serious and less extensive injuries Do not pose a threat to life No threat to life even with delayed treatment

Expectant

Class IV - injuries are not compatible with life Potential for survival does not exist, even with treatment Scare resources reserved for Classes I, II, and III.

lowest

Client least likely to survive= ___________ priority

highest

Client with severe injuries (but potential to survive with treatment) = ____________ priority

Least Restrictive Intervations

Close and constant supervision Assessing medications Bed and wheelchair alarms Mattress on floor next to clients bed

Airway

Highest priority action Must be open and clear Client might need: - Temporary oral or artificial airway (tracheostomy or endotracheal tube) - Supplemental oxygen

Planning

Application of nursing knowledge to the development of the appropriate plan of care. Third step of the nursing process Happens after you analyze the data established client desired outcomes and develop a plan of care.

Survival Potential

Chance client has for survival during mass casualty event Appropriate use of resources to save greatest number of lives. Different from civilian triage system in emergency departments.

Diagnoses (Analysis)

Happens after nurse collects data Second step of nursing process for RNs Lays foundation for making decisions about client's plan of care Takes priority over planning, implementation, and evaluation

Airway, Breathing, Circulation

Priority of initial assessment Referred to as ABCs All are critical to survival Alteration in one could indicate threat to life/need for resuscitation

Least Restrictive

Protects clients civil and legal rights Unauthorized use of restraints can be: - Assault and battery - False imprisonment Use least restrictive methods of restraining first. Physical restraints only when client, staff, or others safety is at risk.

Least Invasive

Reduce number of organisms introduced into body to reduce hospital acquired infections. Reduce client infections to reduce need for antibiotics.

Circulation

Third highest priority Heart rate and blood pressure within expected reference range necessary for adequate cardiac, cerebral, and peripheral perfusion - Chemical and/or physical cardiac support - Resuscitation - Supplemental fluids (to re-establish intravascular fluid volume and blood pressure)

Client Care Focus

Tool to determine priority of nursing actions Each step based on decisions from previous step Most important: Assessment (data collection) first Evaluate client outcomes to determine effectiveness of care plan

love affection relationships involvement with community and spiritual groups help to meet this need.

What are Love and Belonging Needs?

1. Physiological 2. Safety and Security 3. Love and Belonging 4. Self-esteem 5. Self-actualization

What are Maslow's Hierarchy of Needs?

oxygen circulation nutrition elimination fluid balance activity and exercise rest and sleep

What are Physiological Needs?

living in safe environment adequate income shelter from environmental elements

What are Security and Safety Needs?

Personal growth fulfilling own potential very few individuals reach this level.

What are Self-actualization Needs?

self respect personal worth social recognition

What are Self-esteem Needs?

Implementation

is the application of nursing knowledge to the selection of appropriate nursing interventions to promote, maintain, or restore a clients level of health. fourth step of the nursing process happens after its development and takes priority over evaluation

Evaluation

is the judgement you reach regarding the extent to which client goals and outcomes were met. is the fifth step of the nursing process. you can determine the effectiveness of the plan of care based on whether or not the client outcomes were met or are in the process of being met.