Following the shift handoff report on a medical-surgical unit, a registered nurse must determine the sequence of client assessments. Arrange the following clients from highest priority (first) to lowest priority (last).
- 1A client admitted with a deep vein thrombosis who is suddenly reporting sharp chest pain and shortness of breath
- 2A client with type 1 diabetes mellitus reporting tremors and diaphoresis with a capillary blood glucose of 58 mg/dL (3.2 mmol/L)
- 3A client who is 2 days post-appendectomy requesting PRN medication for abdominal pain rated 7 on a 0-10 scale
- 4A client with resolving pneumonia who is asking to review their final discharge instructions before leaving the hospital
Cevap
The correct prioritization sequence is: 1) the client with sudden chest pain and shortness of breath, 2) the client with symptomatic hypoglycemia, 3) the post-operative client requesting pain medication, and 4) the stable client waiting for discharge instructions.
Prioritization of care is determined by assessing the acuity and stability of each client. The most critical framework is Airway, Breathing, and Circulation (ABC). The client with DVT and sudden chest pain/shortness of breath has a life-threatening breathing issue (suspected pulmonary embolism) and must be seen first. The client with symptomatic hypoglycemia has an urgent circulation/metabolic need and is seen second. The post-operative client with pain has an acute but stable need and is seen third. The client requiring discharge teaching is completely stable and represents the lowest priority.
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Anahtar Kavram
Prioritization frameworks such as Airway-Breathing-Circulation (ABC), Maslow's Hierarchy of Needs, and acute versus chronic condition principles are used to determine the sequence of client care.