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NurseReview.Org - Nursing Triage

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Information about NurseReview.Org - Nursing Triage
Career

Published on March 8, 2009

Author: jben501

Source: slideshare.net

Description

Triage is the term derived from the French verb trier meaning to sort or to choose

It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the Right place at the
Right time with the
Right care provider
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Triage in Emergency Department Triage Waiting room Team leader

Definition of Triage Triage is the term derived from the French verb trier meaning to sort or to choose It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the Right place at the Right time with the Right care provider

Triage is the term derived from the French verb trier meaning to sort or to choose

It’s the process by which patients classified according to the type and urgency of their conditions to get the Right patient to the

Right place at the

Right time with the

Right care provider

Triage Categories Non disaster: To provide the best care for each individual patient. Multi casualty/disaster: To provide the most effective care for the greatest number of patients.

Non disaster: To provide the best care for each individual patient.

Multi casualty/disaster: To provide the most effective care for the greatest number of patients.

Non disaster or E.D triage The primary objectives of an ED triage are to (ENA,1992, P. 1): Identify patients requiring immediate care. Determine the appropriate area for treatment Facilitate patient flow through the ED and avoid unnecessary congestion.

The primary objectives of an ED triage are to (ENA,1992, P. 1):

Identify patients requiring immediate care.

Determine the appropriate area for treatment

Facilitate patient flow through the ED and avoid unnecessary congestion.

4. Provide continued assessment and reassessment of arriving and waiting patients. 5. Provide information and referrals to patients and families. 6. Allay patient and family anxiety and enhance public relations.

Disaster Definition: an incident, either natural or human-made, that produces patients in numbers needing services beyond immediately available resources. May involve a large no. of patients or a small no. of patients if their needs place significant demands on resources. The key to successful disaster management is to provide care to those who are in greatest need first and just as importantly, not provide care to to those who have little or no chance of survival. Correct triage is essential to accomplish this goal

Definition: an incident, either natural or human-made, that produces patients in numbers needing services beyond immediately available resources. May involve a large no. of patients or a small no. of patients if their needs place significant demands on resources.

The key to successful disaster management is to provide care to those who are in greatest need first and just as importantly, not provide care to to those who have little or no chance of survival. Correct triage is essential to accomplish this goal

Disaster The triage team Triage of Victims - first victims to arrive are frequently not the most seriously injured. Critical patients Fatally Injured Patients Non critical patients Contaminated patients

The triage team

Triage of Victims

- first victims to arrive are frequently not

the most seriously injured.

Critical patients

Fatally Injured Patients

Non critical patients

Contaminated patients

Types of E.D. triage system Type 1: Traffic Director (Non Nurse). Type 2: Spot Check Type 3: Comprehensive Two-tiered systems: intial screening by RN who greets each patients on arrival, perform a primary survey and determine whether the patient is able to wait for further assessment by a second triage nurse. Divide tasks among staff members, internal triage and external triage

Type 1: Traffic Director (Non Nurse).

Type 2: Spot Check

Type 3: Comprehensive

Two-tiered systems: intial screening by RN who greets each patients on arrival, perform a primary survey and determine whether the patient is able to wait for further assessment by a second triage nurse.

Divide tasks among staff members, internal triage and external triage

Triage levels 1- Resuscitation 2- Emergent 3- urgent 4- less urgent 5- Non urgent The Canadian E.D. Triage and Acuity Scale

1- Resuscitation

2- Emergent

3- urgent

4- less urgent

5- Non urgent

The Canadian E.D. Triage and Acuity Scale

Overview of three category triage acuity systems Rash, chronic headache, sprains, cold symptoms Every 1-2 hrs Non urgent And treatment but time is not a critical factor Class 3 Abdominal pain, non cardiac cp, multiple fractures, lacerations, renal calculi, Every 30 minutes Urgent Requires prompt care, but will not cause loss of life or limb if left untreated for several hours. Class 2 Cardiopulmonary arrest, severe respiratory distress, major burns, major trauma, massive uncontrolled bleeding Coma, status epil.. continuous Emergent Immediately life or limb threatening Class 1 Examples Recommended reassessment acuity category

TRIAGE LEVELS 1- Resuscitation -- threat to life Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE Cardiac and respiratory arrest Major trauma Active seizure Shock Status Asthmatics

1- Resuscitation -- threat to life

Time to nurse assessment IMMEDIATE Time to physician assessment IMMEDIATE

Cardiac and respiratory arrest

Major trauma

Active seizure

Shock

Status Asthmatics

Triage levels 2- Emergent Potential threat to life,limb or function Nurse Immediate , Physician < 15 minutes Decreased level of consciousness Severe respiratory distress Chest pain with cardiac suspicion Over dose (conscious) Severe abdominal pain G.I. Bleed with abnormal vital signs Chemical exposure to eye

2- Emergent

Potential threat to life,limb or function

Nurse Immediate , Physician < 15 minutes

Decreased level of consciousness

Severe respiratory distress

Chest pain with cardiac suspicion

Over dose (conscious)

Severe abdominal pain

G.I. Bleed with abnormal vital signs

Chemical exposure to eye

Triage levels 3- Urgent Condition with significant distress Time Nurse < 20 min, physician < 30 min Head injury without decrease of LOC but with vomiting Mild to moderate respiratory distress G.I. Bleed not actively bleed Acute psychosis

3- Urgent

Condition with significant distress

Time Nurse < 20 min, physician < 30 min

Head injury without decrease of LOC but with vomiting

Mild to moderate respiratory distress

G.I. Bleed not actively bleed

Acute psychosis

Triage levels 4- Less urgent Conditions with mild to moderate discomfort Time for Nurse assessment < 1h Time for physician assessment < 1h Head injury, alert, no vomiting Chest pain, no distress, no cardiac susp. Depression with no suicidal attempt

4- Less urgent

Conditions with mild to moderate discomfort

Time for Nurse assessment < 1h

Time for physician assessment < 1h

Head injury, alert, no vomiting

Chest pain, no distress, no cardiac susp.

Depression with no suicidal attempt

Triage levels 5- Non urgent Conditions can be delayed, no distress Time for nurse and Physician assessment more than 2h Minor trauma Sore throat with temp. < 39

5- Non urgent

Conditions can be delayed, no distress

Time for nurse and Physician assessment more than 2h

Minor trauma

Sore throat with temp. < 39

Basic component of triage An “across-the room” assessment The triage history The triage physical assessment The triage decision

An “across-the room” assessment

The triage history

The triage physical assessment

The triage decision

An “ across the room assessment” To identify obvious life threat conditions General appearance Air way Breathing Circulation Disability (neurogenic)

To identify obvious life threat conditions

General appearance

Across the door assessment The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient. The triage antenna should be seeking clues to problems in all people who enter the triage area If any patient doesn’t look right kindly but quickly interrupt any current interaction and go investigate.

The triage nurse must scan the area where patients enter the emergency door, even while interviewing other patient.

The triage antenna should be seeking clues to problems in all people who enter the triage area

If any patient doesn’t look right kindly but quickly interrupt any current interaction and go investigate.

Across the room assessment Air way Abnormal airway sounds, strider, wheezing grunting Unusual posture e.g.. Sniffing position, inability to speak, drooling or inability to handle secretion Breathing Altered skin signs, cyanosis, dusky skin, tachypnic bradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes

Air way

Abnormal airway sounds, strider, wheezing grunting

Unusual posture e.g.. Sniffing position, inability to speak, drooling or inability to handle secretion

Breathing

Altered skin signs, cyanosis, dusky skin, tachypnic

bradypnea, or apnea periods, retractions, use accessory muscles, nasal flaring, grunting, or audible wheezes

Across the room assessment Circulation Altered skin signs, pale, mottling, flushing Un controlled bleeding Disability (neuro.) LOC Interaction with environment Inability to recognize family members Unusual irritability Response to pain or stimuli Flaccid or hyper active muscle tone

Circulation

Altered skin signs, pale, mottling, flushing

Un controlled bleeding

Disability (neuro.)

LOC

Interaction with environment

Inability to recognize family members

Unusual irritability

Response to pain or stimuli

Flaccid or hyper active muscle tone

Characteristics of triage nurse Extensive knowledge to emergency medical treatment Adequate training and competent skills,language, terminology Ability to use the critical thinker process Good decision maker

Extensive knowledge to emergency medical treatment

Adequate training and competent skills,language, terminology

Ability to use the critical thinker process

Good decision maker

Role of triage nurse Greet patients and identify your self. Maintain privacy and confidentiality Visualize all incoming patients even while interviewing others. Maintain good communication between triage and treatment area maintain excellent communication with waiting area. Use all resources to maintain high standard of care.

Greet patients and identify your self.

Maintain privacy and confidentiality

Visualize all incoming patients even while interviewing others.

Maintain good communication between triage and treatment area

maintain excellent communication with waiting area.

Use all resources to maintain high standard of care.

Role of triage nurse Teaching ----- use of thermometer, first aid ??? avoid lecturing. Crowd control. Telephone. Communicate with team leader and seek feed back on decisions.

Teaching ----- use of thermometer, first aid ??? avoid lecturing.

Crowd control.

Telephone.

Communicate with team leader and seek feed back on decisions.

Importance of re triage Reassess the patient within 1-2hours of initial triage and continue to re assess on a regular basis, patients who may have presented without cardinal signs of severe illness may develop them during long waits. Patients who appear intoxicated actually may have life threatening problems such as DKA, and should not be permitted to keep it off in the waiting room.

Reassess the patient within 1-2hours of initial triage and continue to re assess on a regular basis, patients who may have presented without cardinal signs of severe illness may develop them during long waits.

Patients who appear intoxicated actually may have life threatening problems such as DKA, and should not be permitted to keep it off in the waiting room.

The last person in along line at triage may have a serious medical problem that requires immediate attention Patient should wait no longer than 5 minutes for triage If in doubt about a category, choose the higher acuity to avoid under triaging a patient

The last person in along line at triage may have a serious medical problem that requires immediate attention

Patient should wait no longer than 5 minutes for triage

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