Priority-Setting Frameworks
Maslow’s hierarchy of needs
Least restrictive/invasive → Most restrictive/invasive
Survival Potential
1. Assign a red tag to clients who have life-threatening injuries but have a high
chance of survival with immediate treatment (emergent; first priority for
treatment).
2. Assign a yellow tag to clients who have an urgent condition that could wait
a short time for treatment (urgent; second priority for treatment).
3. Assign a green tag to the walking wounded, or clients who have injuries
that are non-life threatening and could wait hours to days for treatment
(nonurgent; third priority for treatment).
4. Assign a black tag to clients who are deceased or have a minimal chance of
survival despite treatment, and promote comfort for these clients
(expectant; lowest priority).
Urgent v. Nonurgent
Chronic v. Acute
Unstable v. Stable
Airway
Example:
 depression of the central nervous system
 blockages created by blood or vomit
 edema and inflammation of the upper airway
 facial trauma
 foreign objects inside the airway
Evaluating:
 gurgling
 high-pitched wheezing
 ability to talk
 asymmetrical chest wall movement
 absent breath sounds
Intervention:
 head tilt-chin lift or jaw-thrust maneuver
 insert artificial airway
 suction secretions
 Oxygen administration
o 94-96% normally
o 88-92% for COPD
Breathing
Evaluating:
 auscultate the client’s lungs
 obtain a respiratory rate, including depth and pattern FOR ONE FULL
MINUTE
 monitor for central and peripheral cyanosis
 observe for the presence of thoracic wall symmetry as well as the use of
accessory muscles during breathing
Circulation:
 blood pressure
 capillary refill time
 pulse rate, including volume and character
 urine output
 level of consciousness
 changes in skin tone
Disability: neurological status- LOC, response to verbal or painful stimulation,
level of orientation
Exposure: check from head to toe
VITAL SIGNS