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🚦 Who Do You See First? · Lesson 3 of 6 · 6 min

Unstable Beats Stable, Unexpected Beats Expected

⚡ 'Which client should the nurse see first?' is really asking: whose situation is changing right now? A big problem that is old and stable loses to a smaller problem that is new.

💡 Key idea

Ask 'is this expected for this client at this point?' Expected findings wait. New, changing or unexpected findings go first.

🧠 Why it matters

After ABCs and Maslow, apply three filters. ACUTE beats CHRONIC: a new problem outranks a long-standing one. UNSTABLE beats STABLE: changing vital signs, new confusion, new bleeding. UNEXPECTED beats EXPECTED: a finding that does not fit the client's situation outranks one that does. Pain after surgery is expected; sudden calf pain, warmth and swelling three days later is not. A small amount of dark red drainage in the first hours after surgery is expected; bright red drainage soaking a dressing is not. Ask of each option: is this normal for where this client is in their course? If yes, it waits.

🏥 In the real world

🩸 Day one post-op, a client's blood pressure drops from 128/80 to 92/54 and the heart rate climbs to 118. Nothing hurts more than before. Another client on the unit has had chronic hypertension at 160/95 for a decade. The numbers on the hypertensive client look scarier. The post-op client is the one bleeding internally. Trends and changes matter more than any single number.

📌 Takeaways

  • New beats old; changing beats steady
  • Expected findings for the stage of illness or surgery can wait
  • Watch trends: a falling blood pressure with a rising heart rate is hemorrhage until proven otherwise

✅ Test yourself

Which post-operative client should the nurse assess first?
  1. A client 3 days after abdominal surgery with sudden dyspnea and chest pain
  2. A client 1 day after knee surgery with pain 5/10
  3. A client 2 days after a hernia repair with serosanguineous drainage
  4. A client who is anxious about going home tomorrow

Answer: A · A client 3 days after abdominal surgery with sudden dyspnea and chest pain

Sudden dyspnea and chest pain days after surgery suggest a pulmonary embolism, an unexpected and life-threatening change.

A client with long-standing diabetes has a fasting glucose of 160 mg/dL. Another client who is not diabetic has a new glucose of 60 mg/dL and is sweaty and shaky. Who is first?
  1. The non-diabetic client; the finding is new and symptomatic
  2. Whoever called first
  3. Both can wait until the provider makes rounds later this morning
  4. The diabetic client, because 160 is higher and diabetes is a chronic disease

Answer: A · The non-diabetic client; the finding is new and symptomatic

New symptomatic hypoglycemia is acute and unexpected. A modestly elevated fasting glucose in a known diabetic is chronic and stable.

Which finding is EXPECTED and therefore lowest priority?
  1. New onset of confusion in a client who was oriented this morning
  2. Mild incisional pain controlled with the prescribed analgesic
  3. A heart rate that has risen from 72 to 124 over two hours
  4. Bright red blood saturating a dressing 6 hours after surgery

Answer: B · Mild incisional pain controlled with the prescribed analgesic

Controlled incisional pain is expected after surgery. The other three are new changes that need attention.

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