在檢傷分類中,護理師應優先評估下列哪些病患?(選所有適合的)
Which of the following clients should the nurse prioritize during a triage situation? (Select all that apply.)
- AA client with an open fracture of the tibia脛骨開放性骨折的病人
- BA client complaining of substernal chest pain✓ 正解主訴胸骨後疼痛的病人
- CA client with a superficial laceration on the forearm前臂有淺層割傷的病人
- DA client who is unresponsive to verbal stimuli✓ 正解對語言刺激無反應的病人
- EA client with a suspected tension pneumothorax✓ 正解疑似張力性氣胸的病人
檢傷分類(Triage)優先順序依據「威脅生命程度」(Life-threatening conditions)。胸痛(懷疑心肌梗塞)、無反應(意識狀態改變)、張力性氣胸(循環呼吸障礙)皆屬於需立即處理的「紅色」或「橘色」標籤等級。開放性骨折雖然嚴重,但若無大量出血或神經血管受損,優先級次於循環呼吸問題。淺層割傷屬「綠色」標籤,為輕症。
Triage prioritization is based on the degree of threat to life. Chest pain (suspected myocardial infarction), unresponsiveness (altered level of consciousness), and tension pneumothorax (compromise of circulation and respiration) all fall into the red or orange tag categories requiring immediate intervention. An open fracture, although serious, is of lower priority than airway or circulatory problems if there is no massive hemorrhage or neurovascular compromise. A superficial laceration is a green tag, indicating a minor injury.