Triage Flashcards
CTAS
Canadian Triage and Acuity Scale
five level triage system developed to improve patient safety, develop benchmarks, and increase reliability and validity
does not improve or worsen emergebcy room overcrowding
CTAS level 1
name of level 1
resusciation (blue)
CTAS level 2
name of level
emergent (red)
CTAS level 3
name of level
urgent (yellow)
CTAS level 4
name of level
less urgent (green)
CTAS level 5
name of level
non urgent (white)
triage
definition
sorting process utilizing critical thinking in which an experienced RN assesses patients quickly upon their arrival at an emergency setting
components of triage
4
- determine severity of presenting problem
- assign patients into triage category
- determine access to approrpiate treatment
- provide human health resources
benefits of triage
6
- 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
role of triage nurse
6
- assess patients
- communicate with public
- collaborate with healthcare team
- assign resoucres
- initiate treatment protocols
- monitoring/reassessment
triage process
6 steps
- patient encounter (critical first look)
- screening
- noticing (interview and assess)
- interpret (assign CTAS level)
- respond (initiate treatment)
- reflect (reassess as indicated by CTAS level)
first order modifiers
VS, LOC, respiratory distress, hemodynamic stability, pain score, bleeding
second order modifiers
may be required to supplement first order modifiers (blood glucose level, dehydration levels, weakness)
level 1: resuscitation
- conditions that threaten life or limb that require immediate intervention
- obvious signs of distress and unstable VS
should be seen immediately
examples of level 1
cardiac arrest, respiratory arrest, major trauma, severe respiratory distress, GCS 3-9, preterm pregnancy, violent/homicidal behavior
level 2: emergent
potential threat to life, limb, or function, requiring rapid medication intervention
should be seen within 15 minutes
examples of level 2
moderate respiratory distress, GCS 10-13, vomiting blood, symptomatic HTN, severe abdominal pain, chest pain, frostbite, stroke within last few hours, poor perfusion
level 3: urgent
conditions that could progress to a serious problem, significant discomfort, affect ability to function, normal VS
should be seen within 30 min
examples of level 3
mild respiratory distress, hypertension with no symptoms, vomiting and nausea, moderate abdominal pain, moderate headache, uncontrollable diarrhea, blood in stool
level 4: less urgent
conditions that relate to patient age, potential for deterioration that would benefit from intervention within 1-2 hours
should be seen within an hour
examples of level 4
confusion (chronic), UTI complaints with mild dysuria, constipation with mild pain
level 5: non urgent
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
examples of level 5
diarrhea with no dehydration, minor bites, minor acute peripheral pain, uncomplicated dressing change, medication request
when to reasses level 2
every 15-60 minutes
when to reasses level 3
every 30-120 minutes
when to reasses level 4
every 60-120 minutes
when to reasses level 5
every 120 minutes
