A registered nurse on a high-acuity surgical ward has just completed the change-of-shift briefing. Arrange the following clients in the sequence they should be assessed, from highest priority (first) to lowest priority (last).
- 1A client who is 1 day postoperative following a total thyroidectomy, reporting neck pressure and demonstrating inspiratory stridor.
- 2A client with a deep vein thrombosis receiving a continuous heparin infusion who reports a sudden onset of chest pain and hemoptysis.
- 3A client with cirrhosis whose Glasgow Coma Scale (GCS) score has decreased from 14 to 11 over the past two hours.
- 4A client with a closed femur fracture in skeletal traction who is reporting muscle spasms and a pain level of 7 on a 0 to 10 scale.
Answer
The correct sequence of assessment is: 1) The postoperative thyroidectomy client with stridor, 2) The client with deep vein thrombosis experiencing chest pain, 3) The client with cirrhosis and a decreasing GCS score, and 4) The client with a femur fracture reporting muscle spasms.
In nursing prioritization, the ABCs (Airway, Breathing, Circulation) framework and the distinction between unexpected physiological deterioration versus expected findings guide the order of care. The client with a total thyroidectomy exhibiting inspiratory stridor is experiencing an acute airway obstruction, representing the most immediate threat to life, and must be seen first. Next, the client with a deep vein thrombosis presenting with chest pain and hemoptysis is highly suspect for a pulmonary embolism, which is a severe breathing and circulatory emergency. The client with cirrhosis who has had a 3-point drop in their Glasgow Coma Scale score is demonstrating a significant, unexpected neurological decline requiring urgent evaluation, but they have a patent airway and intact circulation, making them the third priority. Finally, the client with a femur fracture in skeletal traction is experiencing muscle spasms and pain, which are expected and non-life-threatening relative to the other conditions, placing them last in the sequence.
Step-by-Step Solution
Key Concept
Prioritization of care using the Airway, Breathing, Circulation (ABC) framework and the distinction between expected and unexpected physiological findings.