While caring for a client with a history of hepatic cirrhosis on the hepatology unit, the nurse observes the client suddenly vomit a copious amount of bright red blood. The client is lethargic, with a heart rate of 142 beats per minute and a blood pressure of 76/42 mm Hg. In what order should the nurse implement the following interventions? Place the actions in sequence from first to last.
- 1Turn the client into a lateral decubitus position.
- 2Provide supplemental oxygen via a non-rebreather mask.
- 3Insert two 18-gauge peripheral intravenous catheters.
- 4Initiate a rapid infusion of 0.9% sodium chloride.
- 5Begin a continuous intravenous infusion of octreotide.
Cevap
The correct sequence prioritizes immediate airway protection, followed by oxygenation, establishing vascular access, initiating fluid resuscitation, and finally administering targeted pharmacological therapy.
In any life-threatening emergency, the nurse must strictly adhere to the Airway, Breathing, and Circulation (ABC) prioritization framework. For a client actively vomiting blood with a lethargic level of consciousness, positional airway protection is the immediate first step to prevent fatal aspiration. This is followed immediately by oxygenation to treat hypoxia. Only after the airway and breathing are secured should the nurse address circulation by establishing large-bore intravenous access and administering fluids to combat hypovolemic shock. Pharmacological interventions specifically targeting the pathology, such as octreotide for varices, are initiated only after the foundational ABCs are completely stabilized.
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Anahtar Kavram
Prioritization of acute variceal hemorrhage management strictly follows the Airway, Breathing, Circulation (ABC) framework.
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