Triage

read em and weep em https://nurseslabs.com/emergency-nursing-triage-nclex-practice-quiz/

Levels of Triage

1. Immediate - resuscitation

2. < 15 minutes - Emergent

3. 15-60 minutes - Urgent

4. 1-2 hours - Semi-urgent

5. 2-24 hours - Non-urgent

Components of a triage assessment

Airway

Breathing

Circulation

Disability

Pain

Basis for gathering data and making clinical decisions. Rapid systematic collection of data. Obtain the chief complaint followed by subjective and objective information

Triage interview

Steps for assigning a triage category

Triage categorization - Level 1

Are they actively dying, and require immediate lifesaving interventions?

Ex:

• Airway is obstructed or partially obstructed

• Apneic

• Intubated

• Severe respiratory distress

• Pulseless, or concern about rate/rhythm/quality

• Hemodynamics and instability?

Does the patient have an acute mental status change that may require immediate life-saving intervention?

• Hypoglycemia

• Heroin OD

• Subarachnoid bleed w/ airway proteciton?

• Does the patient only respond to pain, or are unresponsive?

Triage categorization - Level 2

Shouldn’t wait to provide care. High risk situation? Confused, lethargic, disoriented? Severe pain/distress?

POTENTIAL life or organ threat! Is the patient at HIGH risk of deterioration, is time sensitive!

Acute change in level of consciousness, where the brain is structurally or chemically compromised?

Examples:

• Episode of chest pain

• Newborn with fever

• Rule out → pulmonary embolism, ectopic pregnancy

• Neutropenia w/ fever

• Suicidal , homicidal

• Needlestick in a healthcare worker

• Severe pain or distress

Pediatric fever criteria:

• 1-28 days = Assign at least ESI 2 if temperature is greater than ______

• 1-3 months = Consider ESI 2 if greater than _______

• 3 month - 3 years = Assign ESI 3 if temp is greater than _____, or incomplete _________, or there is no ________

• 1-28 days = Assign at least ESI 2 if temperature is greater than 38C, 100.4F

• 1-3 months = Consider ESI 2 if greater than 38C 100.4F

• 3 month - 3 years = Assign ESI 3 if temp is greater than 102.2F, or incomplete immunizations, or there is no obvious source of fever