An emergency department triage nurse is evaluating four newly arrived clients. Arrange the clients in the order they should be triaged for medical evaluation, from highest priority to lowest priority.
- 1A 28-year-old with facial swelling, stridor, and audible wheezing after an insect sting.
- 2A 55-year-old reporting sudden, crushing substernal chest pain radiating to the jaw with diaphoresis.
- 3A 42-year-old with suspected renal calculus reporting severe flank pain rated 9 on a 0-10 scale and nausea.
- 4A 70-year-old with chronic heart failure reporting bilateral 2+ pitting pedal edema and a 2-pound weight gain over one week.
Cevap
The correct sequence is: first, the client with stridor and facial swelling; second, the client with crushing chest pain; third, the client with severe flank pain; and finally, the client with chronic heart failure and pedal edema.
The prioritization sequence relies on the ABC (Airway, Breathing, Circulation) framework and the Acute vs. Chronic principle. The client with stridor has an imminent airway obstruction, making them the absolute first priority. The client with crushing chest pain requires immediate cardiac evaluation for a potential myocardial infarction (circulation), making them the second priority. The client with the suspected kidney stone is experiencing severe acute pain but has stable vital functions, placing them third. Finally, the client with chronic heart failure has expected, non-acute symptoms without signs of immediate respiratory distress, making them the lowest priority.
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Anahtar Kavram
Prioritization Framework: Airway, Breathing, Circulation (ABC) and Acute versus Chronic