護理長正在審閱多位病人的病歷。基於檢傷原則,哪位病人應優先照護?
A charge nurse is reviewing the medical records of several clients. Which client should be prioritized for care based on the principle of triage?
- AA client with a history of asthma who is currently wheezing✓ 正解有氣喘病史且目前出現喘鳴的個案
- BA client with a closed femur fracture who is in pain股骨閉合性骨折且感到疼痛的個案
- CA client with type 2 diabetes who needs blood glucose monitoring第二型糖尿病且需要監測血糖的個案
- DA client with a stage 2 pressure ulcer requiring a dressing change第二度壓瘡需要換藥的個案
檢傷原則(Triage)優先考慮 ABC(Airway, Breathing, Circulation)。哮喘(Asthma)發作引起的喘鳴(Wheezing)代表呼吸道阻力增加,隨時可能惡化為急性呼吸衰竭,對病人的威脅最立即且嚴重。相比之下,骨折雖疼痛但生命徵象通常穩定,壓瘡與血糖監測屬於慢性照護,優先級較低。
The principles of triage give priority to the ABCs (Airway, Breathing, Circulation). Wheezing from an asthma exacerbation indicates increased airway resistance and may progress to acute respiratory failure at any time, posing the most immediate and severe threat to the client. By comparison, although a fracture is painful, vital signs are usually stable; pressure ulcer care and blood glucose monitoring are chronic care issues with lower priority.