A practical nurse (PN) receives shift hand-off report for four assigned mother-baby couplets on a postpartum unit. In what order should the PN prioritize evaluating these clients? Arrange the clients from highest priority (first) to lowest priority (last).
- 1A client 24 hours post-cesarean birth who reports sudden-onset shortness of breath and a feeling of impending doom.
- 2A client 2 hours following a vaginal delivery whose uterine fundus is boggy and deviated to the right.
- 3A client 12 hours postpartum requesting an as-needed (PRN) analgesic for severe afterpains rated 8 on a 0 to 10 scale.
- 4A client scheduled for discharge in four hours who requires reinforcement of education regarding newborn bathing.
Cevap
The PN should first evaluate the client with sudden shortness of breath, followed by the client with the boggy fundus, then the client with severe afterpains, and finally the client requiring discharge teaching.
Prioritization requires the nurse to first address life-threatening conditions using the Airway, Breathing, and Circulation (ABC) framework. The client with shortness of breath and impending doom is displaying signs of a pulmonary embolism (Breathing), making them the highest priority. The client with the boggy, deviated fundus is at immediate risk for postpartum hemorrhage (Circulation) and is seen second. Once ABCs are stabilized, acute issues such as severe pain are addressed third. Finally, routine and stable interventions, such as reinforcement of discharge teaching, are completed last.
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Anahtar Kavram
Client Care Prioritization using ABCs and Maslow's Hierarchy