The registered nurse (RN) has just received the morning shift report for four clients on a medical-surgical step-down unit. In what order should the RN prioritize the assessment of these clients? Arrange the clients from the highest priority (first to be assessed) to the lowest priority (last to be assessed).
- 1A client with an acute asthma exacerbation who is increasingly lethargic and has significantly diminished breath sounds after receiving a bronchodilator.
- 2A client with a T4 spinal cord injury who is reporting a sudden, severe, pounding headache and exhibits profuse flushing above the chest.
- 3A client receiving a continuous intravenous heparin infusion whose most recent activated partial thromboplastin time (aPTT) is 120 seconds and who has minor oozing at the IV site.
- 4A client with cirrhosis and massive ascites who is requesting an as-needed (PRN) dose of oral spironolactone for abdominal discomfort.
Cevap
The RN should assess the client with asthma first, followed by the client with the spinal cord injury, then the client on the heparin infusion, and finally the client with cirrhosis.
Prioritization in nursing follows the ABCs (Airway, Breathing, Circulation) and severity of the threat to life. The asthma client has an airway/breathing emergency ('silent chest' and lethargy). The spinal cord injury client has a circulatory/neurological emergency (autonomic dysreflexia). The heparin client has an urgent circulatory risk (potential for severe hemorrhage). The cirrhosis client is stable and requires routine care. Therefore, the sequence from most to least critical is: Asthma -> Spinal Cord Injury -> Heparin -> Cirrhosis.
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Anahtar Kavram
Prioritization of care requires evaluating clients based on the ABC (Airway, Breathing, Circulation) framework, followed by addressing systemic medical emergencies, and finally managing urgent physiological risks versus routine chronic needs.