A triage nurse in a busy emergency department is evaluating five newly arrived clients. Based on the principles of prioritization and triage, in what order should the nurse assess these clients? Arrange the clients from highest priority (first) to lowest priority (last).
- 1A client with a suspected bee sting presenting with inspiratory stridor and drooling.
- 2A client with severe pneumonia demonstrating a respiratory rate of 34 breaths/min and new-onset confusion.
- 3A client arriving after blunt abdominal trauma with a heart rate of 128 beats/min and a blood pressure of 88/50 mm Hg.
- 4A client with a history of type 1 diabetes presenting with a blood glucose of 485 mg/dL (26.9 mmol/L) and deep, rapid respirations.
- 5A client with a known deep vein thrombosis (DVT) reporting persistent, aching unilateral calf pain.
Answer
The correct sequence prioritizes the clients from most unstable to most stable: 1) Stridor/drooling (Airway), 2) Pneumonia/confusion (Breathing), 3) Trauma/hypotension (Circulation), 4) DKA/Kussmaul breathing (Metabolic), 5) DVT/calf pain (Routine/Expected).
Prioritization in nursing care is strictly governed by the ABC (Airway, Breathing, Circulation) hierarchy and survival potential. The nurse must first intervene for the client with stridor and drooling, as these are cardinal signs of complete airway obstruction from anaphylaxis. The second priority is the client with pneumonia experiencing acute confusion, which is an early neurological sign of profound hypoxia (Breathing). The third priority is the trauma client exhibiting classic signs of hypovolemic shock (Circulation). Fourth is the client with diabetic ketoacidosis; although this is a critical metabolic emergency requiring continuous IV fluids and insulin, the client's Kussmaul respirations are an expected compensatory mechanism, making them relatively more stable than those with acute, uncompensated ABC failure. The final priority is the client with a DVT, as their localized pain is an expected finding that does not immediately threaten life in the absence of respiratory distress.
Step-by-Step Solution
Key Concept
In emergency triage and priority setting, the nurse must sequence care based on the urgency of physiological needs, strictly adhering to the Airway-Breathing-Circulation (ABC) algorithm while distinguishing between unexpected, life-threatening deterioration and expected disease manifestations.