A practical nurse (PN) enters a client's room and discovers the client lying on the floor beside the bed. The client is awake and states, 'I slipped while trying to get to the bathroom.' Arrange the following actions in the correct priority sequence the PN should perform.
- 1Assess the client's airway, breathing, circulation, and level of consciousness.
- 2Examine the client for visible bleeding, shortening of extremities, or head trauma.
- 3Obtain a complete set of vital signs while the client is on the floor.
- 4Assist the client back into bed utilizing a mechanical lift and additional staff.
- 5Notify the healthcare provider and complete a facility incident report.
Cevap
The correct sequence is to first assess ABCs, then inspect for trauma, obtain vital signs, safely transfer the client to bed, and finally notify the provider and document the incident.
Post-fall management requires a highly structured, systematic approach based on prioritization of physiological needs. Life-threatening conditions (ABCs) must be assessed first. Next, a targeted physical assessment ensures there are no injuries, such as a hip or cervical fracture, that would contraindicate movement. Vital signs are then taken while the client is on the floor to verify hemodynamic stability. Only after completing these three assessment phases is it safe to move the client back to bed using appropriate lift equipment. Finally, secondary tasks like provider notification and incident reporting are performed.
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Prioritization in Post-Fall Management