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Mayna is presented to the ED after a sexual assault. An examination reveals hysteria and emotional distress. Her respiratory rate is 38, her lungs are clear and O2 sat is 96%.
1. Recognize Cues-What information is relevant/irrelevant? What matters most right now?
2. Analyze Cues-What issue is the client at risk for developing or what potential condition could the client be experiencing?
3. Prioritize-What is most likely happening? What should the nurse address first?
4. Generate Solutions-What is the best intervention? What is indicated/contraindicated? Which orders are anticipated?
5. Take Actions-What intervention should be implemented immediately? What can be delegated?
6. Evaluate Outcomes -How do you know the nurse's interventions were effective? What additional interventions should the nurse implement if the initial interventions were not effective?
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