Upon arriving for the day shift on a progressive care unit, the nurse reviews the electronic health records and shift handoff for a group of assigned clients. Prioritize the order in which the nurse must assess the following clients, from most urgent (first) to least urgent (last).
- 1A client admitted with a severe asthma exacerbation whose lung sounds have transitioned from loud expiratory wheezing to diminished breath sounds with increasing restlessness.
- 2A client who is 12 hours postoperative following a total thyroidectomy and reports new-onset circumoral numbness and tingling in the fingertips.
- 3A client receiving a continuous intravenous heparin infusion for a pulmonary embolism whose morning activated partial thromboplastin time (aPTT) is reported as 145 seconds.
- 4A client with a history of chronic right-sided heart failure who presents with 3+ bilateral lower extremity edema and reports a recent 2 kg (4.4 lb) weight gain.
Cevap
The correct sequence is: first assess the client with severe asthma and diminished breath sounds, followed by the client postoperative thyroidectomy with circumoral numbness, then the client on a heparin infusion with an aPTT of 145 seconds, and finally the client with chronic heart failure presenting with peripheral edema.
Prioritization is guided by the ABCs (Airway, Breathing, Circulation) and the principle of treating acute problems before chronic ones. The client with asthma is actively losing their airway (silent chest), making them the highest priority. The post-thyroidectomy client is showing signs of hypocalcemia, which threatens the airway via laryngospasm, placing them second. The client on heparin has a critical lab value threatening circulation (bleeding risk) but is asymptomatic, making them third. The client with heart failure has expected, chronic symptoms and is the most stable, placing them last.
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Anahtar Kavram
Prioritization of client care requires applying the ABCs (Airway, Breathing, Circulation) framework and differentiating between acute, life-threatening conditions and chronic, stable manifestations.