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照護管理 · MEDIUM · SATA

護理師在急診進行檢傷分類,下列哪些病人應優先評估?(選所有適合的)

A nurse is triaging clients in the emergency department. Which client should the nurse see first? (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 reporting severe substernal chest pain✓ 正解
    主訴嚴重胸骨後胸痛的病人
  • CA client with a sudden onset of facial drooping and slurred speech✓ 正解
    突然出現面部下垂和語謇的病人
  • DA client with a superficial burn on the arm
    手臂有淺層燒傷的病人
  • EA client with difficulty breathing and audible wheezing✓ 正解
    呼吸困難且有聽覺可及喘鳴聲的病人
Explanation · 中文詳解

依據 ABC 原則,呼吸道(Airway)、呼吸(Breathing)、循環(Circulation)受損者列為第一優先。胸痛(懷疑心肌梗塞)、中風症狀(腦血管意外)、呼吸困難(氣喘或過敏)均威脅生命,需立即處理。開放性骨折雖然疼痛且需手術,但若無大量出血,優先級低於生命徵象不穩定的個案。淺層燙傷屬於緊急度較低的傷口處理。

Based on ABC prioritization, clients with compromised Airway, Breathing, or Circulation require immediate attention. Severe chest pain suggests myocardial infarction, facial drooping indicates a potential stroke, and difficulty breathing threatens oxygenation; all are life-threatening emergencies. Open fractures and superficial burns, while needing care, are lower priority unless accompanied by hemodynamic instability.

✦ 台美臨床差異

美國急診檢傷系統(如 ESI)非常明確;台灣醫院依各院檢傷流程,但核心邏輯皆遵循 ABC 原則。

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