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Zorluk: KolayPhysiological Adaptation

A client who is restricted to a flat bed rest position suddenly begins experiencing active, forceful emesis. The responding practical nurse (PN) must immediately intervene to stabilize the client. In which order should the PN perform the following actions? (Arrange from first action to last)

  1. 1Assist the client into a side-lying position.
  2. 2Clear the oropharynx using a Yankauer suction catheter.
  3. 3Measure the client's respiratory rate and oxygen saturation.
  4. 4Inform the supervising registered nurse about the episode.

Cevap

The correct sequence is to first turn the client to the side, then suction the airway, followed by measuring respiratory vital signs, and finally notifying the registered nurse.
In any acute physiological event, the nursing process and ABC prioritization dictate that airway protection is the absolute first step. Turning a vomiting, supine client to their side uses gravity to immediately protect the airway. Only after the airway is protected and cleared should the nurse assess vital signs and report the findings.

Adım Adım Çözüm

1
Prioritize the airway by immediately repositioning the client.
The client is moved into a side-lying (lateral) position.
According to the ABC (Airway, Breathing, Circulation) framework, establishing and protecting the airway is the highest priority. A supine client who is vomiting is at severe risk for aspiration.
2
Clear the immediate airway of any remaining obstructions.
The mouth and oropharynx are suctioned.
After using gravity to prevent further aspiration, removing residual emesis ensures the client can breathe without pulling fluid into the lungs.
3
Assess the client's physiological response to the event.
Respiratory rate and oxygen saturation are obtained.
Once the airway is safe, the nurse must assess breathing and oxygenation to determine if aspiration or hypoxia occurred during the episode.
4
Communicate findings to the healthcare team.
The supervising registered nurse is notified.
Escalation of care and reporting should always follow immediate life-saving interventions and the gathering of current assessment data.

Anahtar Kavram

ABC Prioritization in Acute Emesis
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Konular

Physiological Adaptation

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