ENPC 6th Ed Chap 4 Prioritization Flashcards
Can PAT only be used for triage?
No can be used at any time (49 CP)
TICLS mnemonic
Tone, Interactiveness, Consolibility, Look/Gaze, Speech/Cry (49)
SAMPLE mnemonic
Signs/symptoms, Allergies, Medications, Past medical, Last meal, Events leading to illness/injury (60 B)
How should the nurse respond to a caregiver describing a child as being “fussy”?
Considered a red flag for serious illness or injury (61)
At what rate may children be under-triaged?
up to 33% (47)
What three components are assessed during the PAT?
Appearance, Work of breathing, Circulation TO THE SKIN (48)
Under the “Appearance” component of the PAT, what is assessed?
TICLS (48)
Under the “Work of Breathing” component of the PAT, what is assessed?
- Abnormal sounds (stridor, wheeze,grunt)
- Abnormal position (tripod)
- Retractions
- Nasal Flaring
- Apnea/gasping (48)
Under the “Circulation to Skin” component of the PAT, what is assessed?
Pallor, mottling, cyanosis (48)
After using the PAT, how are patient ranked?
sick, sicker, sickest (49)
What are the criteria for “sick, sicker, sickest”? under the PAT assessment?
sick–all patient
sicker –one abnormal PAT assessment
sickest – 2 or more abnormal PAT assessments (50)
If a triaged patients condition changes during the ER visit, what happens to their triage acuity?
“Acuity can change…this does not necessarily mean the triage acuity level changes. (57)
How should the nurse approach any ped with AMS?
Should be considered a decrease in cerebral perfusion or hypoglycemia until proven otherwise. (58)
What percent of childrens crying is due to organic causes?
5% (61)
What temperature elevation at any age is concerning?
> 102.2 (62)
What temperature elevation is concerning in a patient less than 90 days old?
> 100.4 (62)
What low temperature is concerning at at any age?
< 95 (62)
What low temperature is concerning for an infant or neonate?
< 97 may indicate early sepsis (62)
Can you assess a rash during the PAT?
Yes, (62)
When assessing circulation, what capillary refill time is concerning?
> 2 seconds to fill (63)
