A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take?
A. Unequal pupils
B. Irregular pulse
C. Ecchymosis in the flank area
D. A deviated trachea
Correct Answer: D. A deviated trachea
A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated. The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or simply “is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway, if the patient is breathing, and does the patient has a pulse.
Option A: Another scale used by nurses in the assessment is if the patient is meeting criteria for a true level 1 trauma is the AVPU (alert, verbal, pain, unresponsive) scale. The scale is used to evaluate if the patient had a recent or sudden change in the level of consciousness and needs immediate intervention.
Option B: The nurse evaluates the patient, checking pulse, rhythm, rate, and airway patency. Is there concern for inadequate oxygenation? Is this person hemodynamically stable? Does the patient need any immediate medication or interventions to replace volume or blood loss? Does this patient have pulselessness, apnea, severe respiratory distress, oxygen saturation below 90, acute mental status changes, or unresponsiveness?
Option C: If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress? The high-risk patient is one who could easily deteriorate, one who could have a threat to life, limb, or organ.
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