Special Nursing Teams - Types of Triage

forensic nurse examiners

Nurses that are trained to obtain patient histories, collect forensic evidence, and offer counseling, and follow-up care for victims of rape, child abuse, and domestic violence. One example are SANE nurses

abcde approach

To distinguish if there is a life threatening condition, what systematic approach is used?

head tilt chin lift

This method is used to check for foreign bodies in the airway.

jaw thrust

This method is used to open the airway and is indicated for cervical injury.

oropharyngeal airway (opa)

This method is used to prevent the tongue from obstructing the throat.

auscultation, xray, etco2

What is used to confirm placement of an ET tube?

broken ribs

What is expected if there is presence of tenderness during palpation?

tracheal deviation

It indicates either a collapse of lungs or presence of blood, air, or mass on the lungs.

5-6 liters per minute

What is the normal rate of oxygen in a normal nasal cannula?

2-3 liters per minute

What is the normal rate of oxygen in a Venturi mask?

ventricular tachycardia and ventricular fibrillation

What is the most dangerous type of arrhythmias?

2-4 mm

In PERRLA, what is the normal constriction of the eye when exposed to light?

primary assessment

The goal of this assessment is to rapidly but systematically obtain essential subjective and objective information, interpret this information, identify potential life-threatening states, and immediately intervene when indicated.

secondary assessment

The goal of this assessment is to discover all other abnormalities or injuries that are not life-threatening.

arterial line

It is a line that is inserted in the radial artery and attached to a transducer to continuously monitor BP.

mean arterial pressure (map)

This indicator is more reliable than BP, according to doctors.

[(2 x diastolic) + systolic]/3

What is the formula for calculating the MAP?

70-100

What is the normal MAP range?

nature of illness (noi)

It refers to the specific type or character of a patient's medical problem or condition. It's about identifying what is wrong with the patient, rather than just how they present.

triage

An information-collecting and decision-making process. It is performed in order to sort injured and ill patients into categories of acuity and prioritization based on the urgency of their medical or psychological needs.

triage nurse

This nurse collects data and classifies the illnesses and injuries to ensure that the patients most in need of care do not needlessly wait.

emergent, urgent, nonurgent

What are the three categories of triage?

emergent

A triage category considered as the highest priority; clients who require immediate care in order to sustain life or limb.

urgent

A triage category dealing with serious health problems but not life-threatening; clients who require care within 1 to 2 hours to prevent worsening of their condition.

nonurgent

A triage category dealing with episodic illness, clients whose care can be delayed without the risk of permanent consequences.

daily triage

A type of triage that is done on a routine basis at the ER.

incident triage

A type of triage used if the ER has a large number of patients.

disaster triage

A type of triage employed when the local ER is overwhelmed.

tactical-military triage

A type of triage employed when military objectives are used.

special condition triage

A type of triage utilized during MCI (Mild Cognitive Impairment) and WMD (Weapons of Mass Destruction).

crepitus

It indicates the presence of friction inside.

bruit

The presence of the sound indicates a plaque or a block in an artery.

culture and sensitivity

It is used to confirm for correct antibiotic of the patient and reveal which antibiotics are resistant and which are effective.

less than 8

What score in the GCS indicates comatose?

they are able to maintain normal blood pressure until severely compromised

Why is blood pressure not a reliable indicator of perfusion in children?

increased systolic blood pressure with age, making hypotension less obvious

Why is blood pressure not a reliable indicator of perfusion in the elderly?

airway equipment

The first drawer of the crash cart contains what equipment?

breathing equipment

The second drawer of the crash cart contains what equipment?

circulation equipment

The third and fourth drawer of the crash cart contains what equipment?

miscellaneous equipment

The fifth drawer of the crash cart contains what equipment?

1962

In what year was the crash cart first created?

right task, circumstance, person, communication, and supervision

What are the five R's of delegation used in hospital triage?

emergent/resuscitation

In the 5-category triage system, this level includes conditions that threaten life and limb and requires immediate and aggressive interventions.

stable

In the 5-category triage system, this level includes conditions that potentially progress to a serious problem.

less urgent

In the 5-category triage system, this level includes conditions potential for deterioration or complications that would benefit from intervention or reassurance within 1-2 hours.

start triage

It is a rapid approach to triaging large numbers of casualties. It is used for children over 8 yrs. old and adults.

jump start triage

It is a disaster triage system used for children 1-8 years old.

save triage

It is a disaster triage system used when the triage process is extended for a long period of time.

red

In disaster triage, this color is categorized as immediate and is indicated for clients with simple injuries requiring immediate care. They require critical, immediate transport.

yellow

In disaster triage, this color is categorized as delayed and is indicated for clients with multiple injuries requiring extensive care. They require urgent transport.

green

In disaster triage, this color is categorized as minimal and is indicated for clients with minor injuries. They require delayed transport.

black

In disaster triage, the color is categorized as expectant and is indicated for clients with severe injuries likely to cause death. They are considered the last transport priority.

clinical pathways

They are typically generated and used by departments that deliver care for similar conditions to many patients.

practice guidelines

They specify courses of action to be taken in response to a diagnosis or condition.

protocols

They are facility-established sets of procedures for a given circumstance. Their purpose is to outline actions that are most likely to produce optimal patient outcomes.

emt

It is a healthcare professional trained to provide basic lifesaving measures prior to arrival at the hospital.

paramedic

It is a more specialized health care professional trained to provide advanced life support to the client requiring emergency interventions.

emr-emergency medical responder

They are the first responders and are not trained for ambulance service. They include police officers and firefighters.

emt-basic

They provide medical care and are considered the minimum accepted educational level for EMS staff.

emt-intermediate

They proved advanced skills such as manual defibrillation, IVT, medications, and advanced airway devices.

emt-paramedic

It is the most advanced level of pre-hospital care: intubation, HAМ.

star of life

What is the other term for the EMS symbol?

rod of asclepius

What is found at the center of the EMS symbol?

hospital triage, disaster triage, ems

What are the approaches to emergency care?

35-45 mmHg

What is the normal range of ETCO2?