Chapter One: Managing Client Care

Prioritization of Patient Care ABCDE

Principle

- A: Airway – Ensure patient’s airway is patent. At the same time secure the cervical

spine if head or neck injury is suspected. No injury: head-neck, chin lift to secure

airway. Injury: Use modified jaw-thrust maneuver

- B: Breathing – Assess respiratory status. The rate, depth, etc.

- C: Circulation – Assess HR, BP, cap refill, adequate circulation throughout the body

- D: Disability: Assess LOC

- E: Exposure – Assess body for trauma, or exposure to heat or cold Prioritization:

- Always assess before taking action (Dyspnea: assess patient before taking further

action, insulin: assess blood sugar before giving)

- Unstable patients before stable patients (patients with findings that are expected for

their medical diagnosis). COPD patient expected to have low SpO2 whereas patient.

Patient with stroke with facial drooping expected, patient with other diagnosis

having facial drooping unexpected, Albuterol side effects: tachycardia, tremors,

restlessness

(EXPECTED)

- Acute over chronic: Patient with abnormal vital signs, low urinary output are acute

situations and need attention before patients with stage 4 pressure injury (not

developed over night)

- Systemic issues over local issues. Systemic: fever, hypotension, tachycardia

(infection or sepsis). Local: bad skin tear, erythema on the foot (need to address but

others are priority)

- ABCDE: Administering pain medication is RARELY an answer.

- Maslow’s Hierarchy of Needs: Physiological, safety, love and belonging, self-esteem,

self-actualization

- Least invasive interventions before more invasive interventions. (move near nursing

station, sitter, distractions before restraints. Patient difficulty urinating – run water

in room before catheter

Efficient Nursing Practice and Delegation

Efficient Nursing Practice

- Take time at the beginning of sift to plan and prioritize day

- Always chart interventions and nursing care as soon after completing the task as

possible. Throughout the day best practice

- Group tasks for a single patient as much as possible. Get as much supplies for all

patients at once if possible.