Triage Flashcards
Primary goal of triage in the ED:
rapid identifications of urgent, life-threatening conditions
Complementary Goals
Prioritize care needs
Determine most appropriate area for treatment
Regulate patient flow
Provide continued assessment/ reassessment
Provide information/ referrals to client/ family
Relieve client/ family anxiety
Enhance public perceptions
Triage Systems
Type I - Traffic Director (no longer used)
Type II - Spot Check (no longer used)
Type III - Comprehensive
3 Level - Emergent, Urgent, Non-urgent
5 Level - Based on Emergency Severity Index. Endorsed by ENA- most often used
Triage RN Skills
Experienced in skilled rapid assessment
-Determination of patient urgency
-Ability to recognize who needs immediate intervention
Excellent assessment / organizational skills
-Extensive knowledge of diseases / injuries
Ability to communicate with patient / staff
-Verbal
-Written
Triage Categories Level 1
Resuscitation - Requires immediate nursing and medical care.
Prevent loss of life / permanent disability
Cardiac Arrest- CAB- compressions and defibrillation
Major Trauma
Severe Respiratory Distress
Seizures- continuous
Level 2
Requires immediate nursing assessment and rapid treatment
Prevent loss of life / permanent disability
Chest pain
Head Injuries
Stroke
Asthma
Level 3
Must be seen within 30 minutes Serious – not life threatening Multiple ED resources (lab, x-ray, EKG, respiratory therapy) If left untreated for > 2-3 hours may cause permanent disability / death Signs of infection- infx wound Mild Respiratory distress Moderate pain Significant lacerations
Level 4
Must be seen within 1 hour- fast track
One ED resource (lab, x-ray, EKG, respiratory therapy)
If left untreated for > 2-3 hours may cause permanent disability / death
Signs of infection
Mild Respiratory distress
Moderate pain
Chronic Back Pain
Level 5
Requires non-urgent care Minor injury or condition / not life-threatening URI’s Earache Minor lacerations Sprain / strain
First Priority is
to protect yourself from exposure to blood and body fluids by using mandatory standard precautions.
The primary survey is
a rapid assessment to:
Identify life-threatening injuries/ symptoms that must be treated before continuing the assessment
ABCDE
Airway and Cervical Spine ALL patients with multiple trauma are considered to have a C-spine injury until proven otherwise : IMMOBILIZE NECK AND BACK AS NECESSARY Breathing Circulation Disability/Neurologic Exposure / Environment
A = Airway and Cervical Spine
Is the airway Open? Clear of any form of obstruction? To open airway use: Head Tilt / Chin lift (B) Jaw Thrust (A) for suspected Cervical Spine Injury Airway stabilization: Assist Intubate- think about what is going on with pt- know when this would be needed
B = Breathing
Assess Respiratory Rate Depth Inspect for chest wall injury Flail chest, open/sucking chest wound? Palpate for SQ emphysema Asymmetric chest expansion / use of accessory muscles for breathing Ascultate breath sounds Diminished / absent Abnormal Intervene
C = Circulating
Pulse - quality, rate, rhythm Cap refill? Skin color, temperature, moisture LOC Blood Pressure If able to palpate: don’t need to memorize carotid pulse = SBP is 60 femoral = SBP is 70 radial = SBP is 80 pedal pulse = SBP is 100. Identify and control bleeding Use direct pressure If this is not effective apply pressure over major arterial pulse points proximal to the bleeding site. Use a tourniquet as a last resort
D = Disability (neuro check)
Evaluate LOC Pupil response Gross sensory/motor Protect Cervical Spine GCS This can be affected by traumatic as well as toxic and metabolic causes
E = Expose all injuries
Completely undress every trauma patient
Cutting away clothing is usually best to minimize injury and pain
Medical patients need to be undressed for adequate assessment
Minimize heat loss / hypothermia
Use warmed blankets / warmed IV fluids
Protect patient’s privacy and dignity
Secondary Survey is…
detailed head to toe assessment.
“Tubes and fingers in every orifice”
Full set of vital signs
“SAMPLE” Hx
Physical Assessment
Mechanism of injury - circumstances and energy forces that produced the trauma
Blunt- auto accident, fall, fist, baseball bat
Penetrating- knife, gunshot, fall on something sharp
Look for:
Deformities
Contusions
Abrasions/lacerations
Punctures
Secondary Survey “SAMPLE”
S = Subjective data – what happened? A = Allergies M = Medication use P = Past medical history, Primary Physician? L = Last meal, Last tetanus shot (pediatric immunizations), Last menses E = Events or environment related to the injury – include history of abuse
Physical Assessment
Head Neck Chest Limbs Back Perineum Genitalia
Secondary Survey Interviewing Techniques
PQRST
Provokes Quality Radiation Severity Time
Skills
Open ended vs closed ended questions
Active listening
Non judgmental
Gerontological Considerations
Emergencies may be more difficult to assess/ detect due to: Atypical presentation Chronic illness Altered response to treatment Greater risk of developing complications
Pediatric Considerations
Children have smaller airways- more easily blocked by tongue or F.B.
Large head size can contribute to obstruction of airway
Obligate nose breather
Higher metabolic rate = higher O2 demand
Smaller blood volume/ compensatory vasoconstriction/ may see normal BP in presence of significant hypovolemia.
Specific Injuries - Assessment and Management
Abdominal Trauma Poisonings Environmental Emergencies Hemorrhage Tetanus Prophylaxis
Penetrating Abdominal Injuries
Gunshot wounds
Stab wounds
Most important factor is velocity the missile entered body and in what direction
Stab wounds managed more conservatively
Penetrating trauma of the abdomen– high incidence of injury to hollow organs
Penetrating Abdominal Wound
Penetrating Chest Wound
Think Abdomen
Abdominal Trauma
Blunt Trauma
MVC, falls, blows or explosions
Injuries may be hidden/difficult to detect
Can lead to major blood loss into peritoneal cavity
