Deciding who to see first

Three filters, applied in order

A priority question gives four clients and asks who is seen first. Run the list through three filters, in this order, and stop as soon as one of them separates the candidates.

1. Airway, then breathing, then circulation. A threatened airway outranks everything, including a much sicker-sounding problem that is not the airway.
2. Actual before potential. A client who is bleeding now outranks a client at risk of bleeding later.
3. Unstable before stable, and new or unexpected before established. A finding that has changed since the last shift outranks one that has been there for a week.

Findings that jump the queue

Some findings are worth recognizing on sight, because each one is an airway or a circulation about to fail:

• Stridor at rest, a hoarse or muffled voice, or drooling in a child.
• Tingling around the mouth after thyroid surgery — hypocalcemia heading toward laryngospasm.
• A restless, agitated client who was previously settled — early hypoxia, before the saturation falls.
• Sudden chest pain with breathlessness in anyone recently immobile or newly fractured.
• A quiet chest in an asthmatic who was wheezing loudly an hour ago.
• Continuous bubbling in the water seal of a chest drain, or a suddenly deviated trachea.

Notice how many of them are a change rather than an absolute number. A respiratory rate of 28 means little on its own; a rate of 28 in a client who was breathing at 16 this morning means a great deal.

Expected versus unexpected

The other way these questions are built is to offer several abnormal findings, of which three are expected for that client and one is not. A serosanguineous ooze on day one after surgery is expected. Frank blood is not. A temperature of 37.6 in the first hours after an operation is expected. The same temperature on day four is not.

So the question to ask is never "is this abnormal?" but "is this abnormal for this client, at this point?"