ESI and triage Flashcards
The first question a nurse would ask, in which a patient would be triaged as a ESI level 1 if the answer is yes, is…
is the patient dying?
a no would move on to the next step in the algorithm
ESI level 1 patients usually account for __-__% of ED patients
1 - 3%
Name some examples of an ESI level 1 patient
11
Severe respiratory distress
Overdose with respirations <6
Severe bradycardia/tachycardia with hypotension
Traumatic injury with hypotension
Anaphylactic reaction
Hypoglycemia with change in mental status
Chest pain, diaphoretic, with hypotension
Baby that is flaccid
Cardiac arrest
Respiratory arrest
Emergency Bipap
The second question that the nurse should ask him/herself when triaging a patient is what?
What are three other questions that support this question?
Can the patient wait?
- Is the situation high risk?
- Is the patient confused lethargic, or disoriented?
- Is the patient in severe pain or distress?
ESI level 2 patients make up about __-__% of the ED patient population.
20-30%
Name some examples of triage level 2 patients
(24)
I know, I know, it’s a lot
don’t worry, they’re broken down into individual cards later :)
- Chest pain, suspicious of coronary syndrome, with stable vitals
- Healthcare worker with a needlestick
- Signs of a stroke
- R/O ectopic pregnancy
- Fever in the immunocompromised
- Suicidal or homicidal patient
- Change in mental status
- Testicular torsion
- Spontaneous pneumothorax with elevated RR rate
- Seizure
- Patient in severe pain
- Hypertensive crisis
- Peritonsillar abscess
- Inhalation injury with airway compromise
- Hypo/Hyperglycemia
- Sepsis
- Syncope
- Urinary retention
- Sudden change or loss in vision
- Chemical splash to eyes
- Hip / extremity dislocation
- Pelvic /Femur fracture
- Infant > 28 days with a fever
- Accidental/intentional ingestion
If the patient isn’t dying and can wait, what is the third question a nurse should ask him or herself about the patient?
What are three possible answers to the question?
How many resources will the patient need?
- none
- one
- many
Name some ED services that are considered resources.
10
Labs EKG X-ray CT MRI Ultrasound IV, IM, or nebulized medications Specialty consultations Simple procedure = 1 resource (lac repair, Foley cath) Complex procedure = 2 resources (conscious sedation)
After coming to the third question (ESI level 3), name a factor that might make a nurse change their decision to a level 2?
Abnormal vital signs.
The presence of abnormal vital signs may not be enough to upgrade, as it is how meaningful to the patients condition they are.
What are some examples of ESI level 3 Horizontal patients
9
- abdominal pain
- HA/ Migraine
- Flank pain
- Vaginal bleeding with stable VS
- Painful, swollen lower leg pain with no trauma, R/O DVT
- Fractured hip
- Asthma with mild wheezing
- N/V/D
- Fractured, dislocated wrist
What are some examples of ESI level 3 Vertical patients?
6
- Nausea, no vomiting
- Cellulitis
- Low back pain
- Fall that is ambulatory
- MVA that is ambulatory
- Bronchitis
Any infant less than 28 days old that presents with a fever in considered ____ until proven otherwise and should be an ESI level __
septic
2
Any patient known to be pregnant who presents with edema and BP above 150/100 should be considered as ____ and triaged at a priority __
2
pre-eclamptic
If a patient with a head injury presents with neck pain, a blow to the head or chest, and sudden acceleration/deceleration must be considered a C-spine injury until what?
What should be done immediately?
cleared by a physician
C spine precautions should be taken immediatly
All patients less than 12 years of age must be ____, included with vital signs.
weighed
All patients with an eye injury need what?
visual acuity
Priority 2 eye injuries include
3
- sudden pain or loss of vision
- direct blow to the eye with difficulty moving the eye in all directions
- chemicals splashed into the eye
Children and adults who have lost a permanent tooth need to be triaged as a priority __
2
there is a narrow window of opportunity for reimplantation
Bleeding as a post-op complication from a tosilectomy or a tooth extraction needs to be triaged as a priority __
2
Any unstable fracture, deformity, or open fracture should be splinted prior to what?
what are three other things you should do?
going to x-ray
- remember to splint the limb as you find it
- check for pulse and circulation after splinting
- apply ice
What should you tell a person seeking medical advise through a telephone call?
It is Inspira policy to instruct patients to either come to the ED or contact their personal physician.
What should you tell a person who calls in requesting an ambulance?
instruct them to dial 9-1-1
Remove ____ distal to all injuries.
jewelry
what are the four triage questions?
- is the patient dying?
- is this a patient who shouldn’t wait?
- how many resources will this patient need?
- what are the patients vital signs?