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照護管理 · HARD · SATA

護理師正在處理災難現場。進行檢傷分類時,哪些行為是正確的?(選所有適合的)

A nurse is managing a disaster situation. Which actions are appropriate when triaging victims? (Select all that apply.)

  • AAssigning a black tag to a client with a cervical spine injury and no spontaneous breathing✓ 正解
    對頸椎受傷且無自發呼吸的病患貼上黑牌
  • BAssigning a red tag to a client with a controlled hemorrhage and stable vital signs
    對出血已控制且生命徵象穩定的病患貼上紅牌
  • CAssigning a yellow tag to a client with a large open fracture but stable pulses✓ 正解
    對有大面積開放性骨折但脈搏穩定的病患貼上黃牌
  • DAssigning a green tag to a client with minor abrasions and able to walk to the designated area✓ 正解
    對有輕微擦傷且能自行走至指定區域的病患貼上綠牌
  • EAssigning a red tag to a client with a tension pneumothorax✓ 正解
    對張力性氣胸的病患貼上紅牌
Explanation · 中文詳解

災難檢傷分類(START 原則):紅(立即,威脅生命如氣胸),黃(延遲,嚴重但可等待),綠(輕傷,可行走),黑(死亡/無望)。A(黑 tag)符合無呼吸;B(紅 tag)錯誤,受控出血且生命徵象穩定應屬黃色;C(黃 tag)正確,傷勢嚴重但無立即致命;D(綠 tag)正確,符合輕傷定義;E(紅 tag)正確,張力性氣胸若無處置會迅速致命。

Disaster triage using the START principle classifies victims as red (immediate, life-threatening such as tension pneumothorax), yellow (delayed, serious but able to wait), green (minor injuries, ambulatory), and black (deceased/expectant). A (black tag) is consistent with apnea; B (red tag) is incorrect because controlled bleeding with stable vital signs should be classified as yellow; C (yellow tag) is correct because the injury is serious but not immediately life-threatening; D (green tag) is correct and meets the definition of a minor injury; E (red tag) is correct because an untreated tension pneumothorax can rapidly become fatal.

✦ 台美臨床差異

美國護理人員多受過災難應變訓練(如 FEMA 認證);台灣此類大規模災難檢傷多由救護技術員或急診醫師主導。

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