A registered nurse enters a client's room and finds the client lying on the floor near the bathroom. The client states, 'I slipped and fell on my way to the toilet.' Arrange the following nursing interventions in the correct sequence of priority, from first to last.
- 1Assess the client's airway, breathing, circulation, and level of consciousness.
- 2Evaluate the client for physical injuries such as lacerations, bleeding, or deformities.
- 3Call for assistance from other staff members to safely transfer the client back to bed.
- 4Notify the primary healthcare provider of the fall and the clinical assessment findings.
- 5Complete a facility incident report and document the event objectively in the medical record.
Cevap
The correct sequence of actions for a client found on the floor is: assess ABCs and level of consciousness, perform a physical assessment for injuries, obtain assistance to move the client to bed, notify the provider, and finally complete the incident report.
In the event of an unwitnessed fall, the nurse must prioritize assessment over intervention. The sequence follows the nursing process and emergency prioritization: first, assess ABCs (most critical); second, assess for localized injuries before moving; third, safely intervene by moving the client with help; fourth, communicate with the provider; and fifth, document the occurrence.
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Anahtar Kavram
The nursing process and the ABC framework dictate that physiological assessment for life-threatening conditions precedes all other interventions, followed by safety measures, communication, and finally documentation.