At the beginning of the shift on a pulmonary step-down unit, the nurse reviews the handover notes for four assigned clients. Order the clients from highest to lowest priority for the initial assessment.
- 1A client with Guillain-Barré syndrome who exhibits a rapidly decreasing forced vital capacity over the past hour
- 2A client receiving a continuous intravenous heparin infusion for a pulmonary embolism who reports new-onset hemoptysis
- 3A client with bacterial pneumonia and a temperature of 102.4°F (39.1°C) who is due for scheduled intravenous antibiotics
- 4A client with a closed-chest drainage system for a pneumothorax demonstrating continuous bubbling in the suction control chamber
Cevap
The correct sequence prioritizes impending respiratory failure first, followed by a critical bleeding complication, an acute systemic infection, and finally a stable client with an expected equipment finding.
The priority of care must strictly follow Maslow's hierarchy of needs and the ABC framework. The client with Guillain-Barré syndrome is losing diaphragmatic function (Breathing), which is fatal within minutes if unaddressed. The client with hemoptysis on heparin has a severe bleeding complication (Circulation). The pneumonia client requires timely medication but is not crashing. The chest tube client exhibits entirely normal equipment function and is stable.
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Anahtar Kavram
Prioritization of Care using the ABC Framework and Expected vs. Unexpected Findings