Maslows Hierarchy of Needs

Physiological:
o Oxygenation, circulation, nutrition, elimination, fluid balance,
activity and exercise, and rest and sleep
Safety and Security:
o Living in safe environment, adequate income, shelter from
environmental elements
Love and Belonging:
o Love, affection, social relationships
Self-Esteem:
o Self-respect, personal worth, social recognition
Self-actualization
o Personal growth, fulfilling own potential
Nursing Process
Assessment
Analysis
Planning
Implementation
Evaluation
ABCs Framework
Airway (must be open and clear)
o Highest priority
o Client might need temporary oral or artificial airway (Trach or
EndoTrach tube)
o Might need supplemental oxygen to maintain an adequate level
Breathing
o Second highest priority
o Essential for oxygen exchange:
Respiratory rate within expected reference range, and
adequate ventilator effort
o Client might need:
Artificial ventilation
Negative pressure gradient in pleural cavity
Chest tube might re-establish negative pressure
Circulation
o 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-stablish intravascular fluid

volume and blood pressure).
Safety and Risk Reduction
Assigns priority to the factor or situation posing the greatest:
o Safety risk to the client
o Greatest risk to the clients physical priority setting framework
to identify risk posing greatest threat
Sources of Safety Issues
o Client
o Nurse
o Provider
o Medical equipment and environment
o Home environment
o Community
Least Restrictive/Least Invasive
Priority goes to interventions that are least restrictive and least
invasive to a client.
Make sure it wont put the client at risk for harm or injury.
Least restrictive
o Protect clients civil and legal rights
o Unauthorized use of restraints can be:
Assault and battery
False imprisonment
o Use least restrictive methods of restraining first.
o Physical restraints only when client, staff, or others safety is
at risk.
Least invasive
o Reduce number of organisms introduced into body to reduce
hospital acquired infections
o Reduce client infections to reduce need for antibiotics
Survival Potential
Class 1 - Emergent
o Life threatening injuries
o Immediate treatment = chance for survival
o Highest priority
Class 2 Serious and extensive injuries
o Do not pose immediate threat to life
o Potential for survival even with delayed treatment
Class 3 Nonurgent
o Less serious an dless extensive injuries
o Do not pose a threat to life

o
Class
o
o
o
o

No threat to life even with delayed treatment

4 Expectant
Injuries are not compatible with life
Potential for survival does not exist, even with treatment
Scarce resources reserved for Classes 1, 2, and 3.
Class 1 is the highest priority

Acute over Chronic Clients

Acute needs get priority because they may pose more of a threat
Chronic needs develop over a period of time
Attend to alteration in acute phase before they evolve into chronic
alteration
Urgent over Non-Urgent Client
Urgent needs pose more threat to client
Needs become urgent when related to an intervention needed
within a specified time
When caring for a group of clients, attend to the client with the
most urgent need first.
Unstable over stable clients
Unstable clients get priority because the clients have needs that
pose threat to clients survival.
Life-threatening needs often involve airway, breathing, or
circulatory status.
Client at risk for becoming unstable are higher priority than clients
who are stable.