A key concept in nursing is prioritizing patient care, and this can be a difficult concept for new students and even new nurses to fully understand. It’s definitely one of those things that gets much more intuitive with a lot of repeat practice. 

The first thing to understand about prioritizing is that your (and the patient’s) priorities are going to constantly fluctuate, so you must always be reassessing and reevaluating what is most urgent and important for your patient at any given time. A helpful way to establish priorities is to classify them as urgent, intermediate and low priority. And one to differentiate between urgent, intermediate and low priorities is to utilize a framework such as the ABCs and Maslow’s Hierarchy of Needs. 

It’s also important to understand that in the acute care setting, you are not just prioritizing one patient’s problems in isolation. They must be considered in relation to all your patients’ problems. When you are caring for more than one patient, you will need to organize the workflow of your shift, determine who you need to assess first, and make decisions about which patients require intervention first.

High priority problems are those that could cause harm to the patient if left untreated. For example, if the patient’s airway is occluded, this is a high priority as failing to open the airway will quickly result in significant patient harm. In fact, all patient problems associated with the ABCs are high priority problems and must be quickly addressed prior to considering lower-priority issues such as pain or hypertension.

As a reminder, the ABCs stand for airway, breathing, and circulation. You learned how to assess for the ABCs and how to intervene in the basic life support class you were required to complete prior to starting nursing school. Basic interventions for the ABCs include maintaining a patent airway, providing oxygen or assisting breathing with a BVM, and performing chest compressions in a pulseless patient.

However, not all patient problems are so distinctly a high priority, which is where a framework such as Maslow’s hierarchy comes into play. 

What is Maslow’s hierarchy of needs?

Maslow’s hierarchy of needs is a motivational theory that involves five levels of human needs. According to this theory, more basic needs must be met before higher-level needs can be fulfilled. 

Maslow's Hierarchy

The two foundation needs, physiological and safety/security are considered basic needs and much of your nursing care will be aimed at addressing these needs, though all levels of the hierarchy can be involved in patient care. 

  • Physiological needs – Food, fluids, warmth, elimination, rest, and, of course, the ABCs all fall under physiological needs. For example, you meet a patient’s physiological needs when you maintain an open airway or provide nutrition.
  • Safety and security needs – Keeping patients free from harm, preventing injury, preventing infection, preventing complications related to their underlying disease condition or treatments, building trust with patients. For example, you help the patient meet these needs by performing hand hygiene, which prevents infection or by encouraging ambulation, which helps prevent pneumonia and DVT.
  • Love and belonging needs – Ensuring the patient has adequate support systems could mean involving family in the plan of care, or working with case management or the social worker to identify available resources. For example, attending a stroke survivor’s support group can provide a patient with emotional support and prevent feelings of isolation while recovering from a stroke.
  • Self-esteem needs – Helping the patient understand how to manage their disease condition and providing them opportunities to share their feelings can help meet their needs for self-esteem. For example, teaching a patient newly diagnosed with type 2 diabetes how to measure their blood glucose and administer the proper amount of insulin provides them with a feeling of control and accomplishment.
  • Self-actualization needs – Providing an environment where the patient can improve their health through personal growth or spiritual pursuits. For example, arranging for the hospital chaplain to meet with the patient for daily counseling and prayer can help a spiritual patient meet this high-level need.

How to utilize the ABCs and Maslow’s hierarchy to prioritize care

When faced with a clinical scenario either in-person or on an exam, physiological needs (including the ABCs) are always going to take priority over other needs. From there, work your way up Maslow’s hierarchy ensuring that safety needs are met before addressing belonging or self esteem needs. Here are a few examples: 

Example #1:

Your patient had a lobectomy of the right lower lobe yesterday afternoon. What is the priority intervention? 

  1. Ensure the patient ambulates three times today.
  2. Teach the patient how to care for their surgical incision.
  3. Provide pain medication for the patient’s 6/10 pain.
  4. Provide supplemental oxygen for an SpO2 of 87% on RA.

Let’s look at each of these options and how they fall on Maslow’s hierarchy. 

  1. Ensure the patient ambulates three times today – This meets a need for safety by preventing the complications associated with immobility such as pneumonia, DVT and deconditioning.
  2. Teach the patient how to care for their surgical incision – This meets a need for self-esteem by teaching the patient how to perform their own care after discharge.
  3. Provide pain medication for the patient’s 6/10 pain – This meets a basic physiological need to be free from pain.
  4. Provide supplemental oxygen for an SpO2 of 87% on RA – This meets a basic physiological need related to the ABCs.

Note that this question has two possible options that fall under basic needs – respiratory insufficiency and pain. In fact, all four options are appropriate, but the one that is the most appropriate addresses one of the ABCs (breathing). In this scenario, you will first support the patient’s respiratory status by providing supplemental oxygen.

Example #2

You are caring for four patients on the telemetry unit. Which patient problem will you address first?

  1. Bud needs to learn how to manage his Foley catheter before being discharged.
  2. Silvia has a blood pressure of 78/42 with delayed capillary refill and cool extremities.
  3. Chuck has dementia, diabetic neuropathy, and is trying to get out of bed.
  4. Roberta is stable and pending discharge once the physician can review her stress test results in the morning. She is demanding to leave AMA if her boyfriend isn’t allowed to visit after hours.

As a student or new nurse (even an experienced nurse) having all these competing priorities can be challenging to manage. Let’s go through each option. 

  1. Bud needs to learn how to manage his Foley catheter before being discharged – While this does need to occur so that the patient can meet their goals, it is not a priority intervention at this time. Teaching Bud how to manage his catheter can wait a few minutes while you address more basic needs.
  2. Silvia has a blood pressure of 78/42 with delayed capillary refill and cool extremities – This is a basic physiological need that has priority over others at this time.
  3. Chuck has dementia, diabetic neuropathy, and is trying to get out of bed – Keeping Chuck safe meets his basic need for safety, but Silvia’s blood pressure is even more of a foundation need. If possible, you could delegate this to a CNA.
  4. Roberta is stable and pending discharge once the physician can review her stress test results in the morning. She is demanding to leave AMA if her boyfriend isn’t allowed to visit after hours – While we never want a patient to leave AMA, Roberta’s need to control her situation and reassert her self esteem is not as high a priority as addressing Silvia’s blood pressure. 

Example 3:

You’re working on the med surg unit. Which patient requires your attention first? 

  1. Jack, who has a history of OA in his left knee is requesting pain medication for a pain level of 4/10.
  2. Marvin, who states he has chest pain after eating some spicy Mexican food his family brought in.
  3. Jessica, who has a history of seizures, is complaining of feeling a bit lightheaded.
  4. Irving, who suffers from constipation, feels like he could have a bowel movement if he goes to the commode immediately.

Maslow’s hierarchy isn’t always easy to apply to scenarios that are all based on physiological components. Each of these patients has a basic physiological need, but only one is the priority. To determine the priority, refer to the ABCs. Which patient is having an issue with one of the ABCs?

The answer is Marvin, who is complaining of chest pain. The fact that it occurred after eating spicy food (and could simply be heartburn) does not rule out the need for prompt further assessment. Since chest pain could indicate a serious compromise with the cardiac system, it’s part of the ABCs and the highest priority.

Example 4: 

You’re working on a medical-surgical unit and have just received report on four patients. Which patient will you assess first?

  1. Daniel, who received an IV dose of morphine by the night shift nurse just prior to report.
  2. Louise, who had a cholecystectomy yesterday and needs assistance getting from the bed to the chair for breakfast.
  3. Gregory, who has a potassium level of 5.5 and just received his 0600 dose of furosemide.
  4. Patrice, whose WBC count was 13000 on this morning’s labs.

Of these patients, only one is at risk for a complication related to the ABCs, and that’s Daniel. Let’s look at the rationales:

  1. Daniel, who received an IV dose of morphine by the night shift nurse just prior to report. – Intravenous opioids can quickly take effect and cause respiratory depression. Assessing Daniels’ respiratory status and level of sedation takes precedence over these other patient’s needs.
  2. Louise, who had a cholecystectomy yesterday and needs assistance getting from the bed to the chair for breakfast. – While patient mobility is important, this can wait or be delegated to an unlicensed assistant such as a CNA.
  3. Gregory, who has a potassium level of 5.5 and just received his 0600 dose of furosemide. – A potassium level of 5.5 is at the high end of normal, but since you know furosemide will cause this level to drop slightly, you are not concerned about hyperkalemia at this time.
  4. Patrice, whose WBC count was 13000 on this morning’s labs. – Before determining if this is a priority assessment, you look at the trend of the WBCs and note that yesterday’s count was 14.5K. You also check the MAR and see the patient is receiving IV antibiotics. For this patient, a WBC of 13,000 is an improvement and shows the treatment plan is working as intended.

Pro Tips for Effective Prioritization

  • View prioritization as a constant, ever-changing activity. Every time you assess or intervene for your patients, think through your priorities as they have likely changed.
  • Your patient’s physiological needs are of the highest priority. Within that group, the ABCs must be addressed before any other.
  • Involve patients in priority setting when possible. For example, if consulting with the chaplain is more important to the patient than learning how to care for their wound, then you would assign greater priority to this need for self-actualization.
  • Consider your available resources when determining your priorities. For example, many times lower-level priorities can be delegated to assistive personnel. Read this post for tips on effective delegation.
  • Don’t become so linear in your thinking that you don’t recognize new problems or priorities as they arise. For example, a patient suddenly developing shortness of breath would take priority over most other assessments and interventions. Additionally, new orders you weren’t expecting will likely disrupt your planned workflow and must be considered as you plan your patients’ care.

Review how to prioritize patient care with the ABCs and Maslow’s hierarchy for your exams, clinicals, and NCLEX while you’re on the go by tuning in to episode 333 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.

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