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학습 자료 둘러보기 →Scenario: A 35-year-old worker with 40% TBSA burns, RR 28, capillary refill >2 seconds, alert.
Key Assessment Finding: The prolonged capillary refill time (>2 seconds) is the critical determinant. In the START algorithm, abnormal perfusion immediately classifies the patient as Red (Immediate), regardless of the respiratory rate or mental status, as long as the patient is breathing and has a perfusing rhythm.
Immediate Actions:
NCLEX Practice Point: For the NCLEX, remember the START algorithm sequence: 1) Check Respirations (if none, open airway; if still none, tag Black). 2) If breathing, check rate (>30/min = Red). 3) Check Perfusion (capillary refill >2 sec or absent radial pulse = Red). 4) Check Mental Status (unable to follow commands = Red). Only if all are normal is the patient tagged Yellow or Green.
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.