While conducting morning rounds on a medical-surgical unit, the practical nurse discovers a client lying on the floor beside the bathroom door. The client is awake and states, 'I slipped and fell.' Arrange the following nursing actions in the correct priority order from first to last.
- 1Perform an immediate assessment for changes in level of consciousness, pain, and visible deformities.
- 2Activate the emergency call system to request staff assistance without leaving the client.
- 3Measure the client's vital signs while they remain in the position found.
- 4Transfer the client safely back to bed using mechanical lifting equipment and personnel.
- 5Complete an objective facility occurrence report regarding the unobserved fall.
Cevap
The correct sequence of actions is: perform an initial assessment for injuries, activate the call system for staff assistance, obtain vital signs on the floor, transfer the client safely back to bed, and finally complete the occurrence report.
In any post-fall scenario, the nursing process mandates that physical assessment must occur first. The nurse must quickly evaluate the client for catastrophic injury before doing anything else. Second, the nurse must summon help while remaining with the client to ensure safety. Third, a full set of vital signs is obtained to check for internal stability. Fourth, once cleared of major injury, the client is safely moved using adequate personnel and equipment. Finally, institutional documentation such as an occurrence report is completed.
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Priority Setting in Post-Fall Management
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