Triage

Question 1

CTAS

Canadian Triage and Acuity Scale

Answer 1

five level triage system developed to improve patient safety, develop benchmarks, and increase reliability and validity

does not improve or worsen emergebcy room overcrowding

Question 2

CTAS level 1

name of level 1

Answer 2

resusciation (blue)

Question 3

CTAS level 2

name of level

Answer 3

emergent (red)

Question 4

CTAS level 3

name of level

Answer 4

urgent (yellow)

Question 5

CTAS level 4

name of level

Answer 5

less urgent (green)

Question 6

CTAS level 5

name of level

Answer 6

non urgent (white)

Question 7

triage

definition

Answer 7

sorting process utilizing critical thinking in which an experienced RN assesses patients quickly upon their arrival at an emergency setting

Question 8

components of triage

4

Answer 8

1. determine severity of presenting problem
2. assign patients into triage category
3. determine access to approrpiate treatment
4. provide human health resources

Question 9

benefits of triage

6

Answer 9

• ensures critical and injured patients receive care before less ill/injured
• establishes acuity
• helps inform treatment and required resources
• identifies frequency of reassessment
• space and resource utilization
• timely approach

Question 10

role of triage nurse

6

Answer 10

• assess patients
• communicate with public
• collaborate with healthcare team
• assign resoucres
• initiate treatment protocols
• monitoring/reassessment

Question 11

triage process

6 steps

Answer 11

1. patient encounter (critical first look)
2. screening
3. noticing (interview and assess)
4. interpret (assign CTAS level)
5. respond (initiate treatment)
6. reflect (reassess as indicated by CTAS level)

Question 12

first order modifiers

Answer 12

VS, LOC, respiratory distress, hemodynamic stability, pain score, bleeding

Question 13

second order modifiers

Answer 13

may be required to supplement first order modifiers (blood glucose level, dehydration levels, weakness)

Question 14

level 1: resuscitation

Answer 14

• conditions that threaten life or limb that require immediate intervention
• obvious signs of distress and unstable VS

should be seen immediately

Question 15

examples of level 1

Answer 15

cardiac arrest, respiratory arrest, major trauma, severe respiratory distress, GCS 3-9, preterm pregnancy, violent/homicidal behavior

Question 16

level 2: emergent

Answer 16

potential threat to life, limb, or function, requiring rapid medication intervention

should be seen within 15 minutes

Question 17

examples of level 2

Answer 17

moderate respiratory distress, GCS 10-13, vomiting blood, symptomatic HTN, severe abdominal pain, chest pain, frostbite, stroke within last few hours, poor perfusion

Question 18

level 3: urgent

Answer 18

conditions that could progress to a serious problem, significant discomfort, affect ability to function, normal VS

should be seen within 30 min

Question 19

examples of level 3

Answer 19

mild respiratory distress, hypertension with no symptoms, vomiting and nausea, moderate abdominal pain, moderate headache, uncontrollable diarrhea, blood in stool

Question 20

level 4: less urgent

Answer 20

conditions that relate to patient age, potential for deterioration that would benefit from intervention within 1-2 hours

should be seen within an hour

Question 21

examples of level 4

Answer 21

confusion (chronic), UTI complaints with mild dysuria, constipation with mild pain

Question 22

level 5: non urgent

Answer 22

conditions that may be acute but non-urgent, or a part of a chronic problem, no evidence of deterioration. Interventions could be delayed

should be seen within an hour and a half

Question 23

examples of level 5

Answer 23

diarrhea with no dehydration, minor bites, minor acute peripheral pain, uncomplicated dressing change, medication request

Question 24

when to reasses level 2

Answer 24

every 15-60 minutes

Question 25

when to reasses level 3

Answer 25

every 30-120 minutes

Question 26

when to reasses level 4

Answer 26

every 60-120 minutes

Question 27

when to reasses level 5

Answer 27

every 120 minutes