ABCs And Emergency Priorities - NCLEX-RN

Activate emergency response and start CPR. For an unresponsive client without normal breathing, immediate activation of emergency response and initiation of CPR are essential to restore circulation and oxygenation.

Obstructed airway. In emergency prioritization, an obstructed airway poses an immediate threat to oxygenation and life, taking precedence over non-life-threatening conditions like pain or anxiety.

Airway, Breathing, Circulation. This mnemonic prioritizes life-threatening issues by addressing airway patency first, followed by breathing effectiveness, and then circulatory adequacy in emergency nursing care.

Stridor. Stridor signals upper airway obstruction, requiring urgent intervention to prevent respiratory failure, unlike crackles or pleuritic pain which are less immediately threatening.

Blood pressure, pulse quality, and capillary refill. These parameters directly assess perfusion and circulatory adequacy, providing critical data on hemodynamic stability in unstable clients.

Cool, clammy skin. Cool, clammy skin indicates poor perfusion and compensatory vasoconstriction in shock, demanding immediate circulatory interventions unlike fever alone.

Direct pressure on the wound. Direct pressure controls hemorrhage by promoting clot formation and stabilizing circulation, serving as the first-line intervention for external bleeding.

Apply a tourniquet proximal to the wound. A tourniquet occludes arterial flow to stop life-threatening hemorrhage when direct pressure is ineffective, following hemorrhage control protocols.

Active GI bleed with hypotension. Active gastrointestinal bleeding with hypotension compromises circulation and perfusion, posing a greater immediate threat than stable pain from a fracture.

Prepare for immediate needle decompression. Tension pneumothorax causes mediastinal shift and cardiovascular collapse, requiring urgent needle decompression to relieve pressure and restore ventilation.

Accessory muscle use. Accessory muscle use signifies increased work of breathing and impending respiratory fatigue, indicating a higher risk of failure than isolated wheezing.

Administer intramuscular epinephrine. Intramuscular epinephrine rapidly reverses bronchoconstriction and hypotension in anaphylaxis, addressing airway and breathing threats as the primary intervention.

New confusion with $SpO_2$ 86%. New confusion with low $SpO_2$ suggests acute hypoxemia affecting cerebral function, prioritizing it over chronic pain due to immediate threat to brain oxygenation.

Support ventilation and give naloxone. In opioid overdose, supporting ventilation prevents hypoxia while naloxone reverses respiratory depression, addressing the primary breathing emergency.

Assess oxygenation and airway/breathing. Sudden restlessness and tachycardia often indicate hypoxia, making oxygenation and airway/breathing assessment the initial step to identify and correct underlying causes.

Emergent (immediate). The emergent category in triage systems identifies clients with immediate life threats, ensuring rapid interventions to prevent deterioration.

Severe asthma with silent chest. Silent chest in severe asthma indicates profound airflow obstruction and impending respiratory arrest, requiring more urgent attention than mild symptoms.

Activate stroke protocol and obtain rapid glucose. Activating stroke protocol facilitates timely imaging and treatment, while checking glucose rules out hypoglycemia mimicking stroke symptoms within the critical window.

Hypoglycemia with altered mental status. Hypoglycemia causes rapid neurological deterioration, making it a higher priority than hyperglycemia, which typically presents with less acute symptoms like thirst.

Maintain airway and elevate head of bed. Maintaining airway patency prevents aspiration from vomiting, while head elevation reduces intracranial pressure by promoting venous drainage.

Septic client with MAP 55. Low mean arterial pressure in sepsis indicates circulatory shock and organ hypoperfusion, prioritizing it over stable fever without hemodynamic instability.

Apply oxygen and assess airway/breathing. Sudden chest pain with dyspnea and cyanosis suggests a critical oxygenation issue, necessitating immediate oxygen administration and airway/breathing assessment to stabilize the client.

RR 10. A respiratory rate of 10 indicates bradypnea, potentially signaling respiratory depression or failure, which requires more urgent intervention than tachypnea or normal rates.

Abdominal thrusts (Heimlich maneuver). Abdominal thrusts dislodge foreign body obstructions in conscious clients, restoring airway patency as the initial life-saving measure per choking protocols.