영어/NCLEX

[Safety and infection control] Disaster triage

선키 2024. 6. 11. 19:57

Prioritize : Client with paradoxical chest movement throughout respirations. 

 

Disaster Triage Characteristics Examples
Emergent Life-threatening injuries with high probability for survival if immediate treatment is received -Shock
-Compromised airway
-Unstable wounds
-Chest trauma
Urgent Serious injuries requiring treatment within 30 min and 2 hr -Open fractures with palpable distal pulse
-Large wounds
Nonurgent Injuries requiring treatment but can wait for 2 hr or longer -Infections
-Minor burns or lacerations
-Closed fractures
Expectant Extensive injuries with poor prognosis, regradless of treatment -Pulselessness
-Apnea
-Severe neurological trauma
-Full-thinkness burns > 60% total body surface area

 

Why I thought client who is at 8 weeks gestation with spotting and pulse of 90/min.

: Spotting at 8 weeks gestation may indicate complications of pregnancy (eg. miscarriage, ectopic pregnancy, hydatidiform mole). With stable vital sign, this client would be classified as nonurgent as the fetus is not at the age of viaility and there is no evidence of risk to the mother's life.

 

Client with a compound femoral fracture and an oozing laceration -> urgent 

Client with fixed and dilated pupils and no spontaneous respirations -> Expectant

Client with paradoxical chest movement throughout respirations -> flail chest from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent!! due to airway compromise, which requires immediate treatment.

 

 

If a visitor is seen lying on the hallway floor, it is more important than the infusion is beeping in a client who is receiving blood. IV line will not occlude waiting a few minutes to be dealt with.