CRISTOBAL, ROCELYN P.

Post Task: TRIAGE Sorting of Patients in the Emergency Department and Immediate Care

DIRECTION: Given the 6 different cases, as a nurse assigned in the emergency department, apply your knowledge of
Triage (Australasian Triage Scale), and prioritize the following patients who presented in the Emergency Department.
Among the 6 different cases that you categorized, select your first 2 patients, give your immediate nursing intervention
and justify your actions.

TRIAGE CLASSIFICATION IMMEDIATE NURSING INTERVENTION

(Australasian Triage Scale) /Justification

Category I RED Justification:

A 68 year old male client was brought to the emergency
room by his relatives. Upon initial assessment, the client
was unable to move the left side of his body, has slurred
speech, and has a history of chronic hypertension. Vital
signs are: BP 180/100, HR 120 bpm, RR 24 rpm, O2
saturation 88 %
This is the first priority case because of its increased
blood pressure, manifestation of hypoxemia, increased rr
and the patient was unable to move the left side of the
body upon the arrival. The overall condition manifested as
hypoxia or anoxia which usually resulted in STROKE. Rule
of thumb in facility setting FIRST TO DIE, FIRST TO SEE.
And this is a life threatening condition and must be seen
PRN.
Nursing Interventions with Justification:

Independent:

1. Upon arrival of the patient in the ED, the nurse

should never pull on the affected arm. Guide the
upper extremity movement from the scapula and not
from the arm; use a lift sheet to reposition in bed.
Ensure that the arm has a firm support surface when
the patient is sitting.These measures help prevent
subluxation. When in bed the shoulder should be
positioned slightly forward to counteract shoulder
rotation. The affected arm should be placed in
external rotation when the patient is supine or lying
on the affected side.

2. Teach methods for turning and moving, using the

stronger extremity to move the weaker extremity.
This will help to move the affected leg in bed or
when changing from a lying to a sitting position,
slide the unaffected foot under the affected ankle to
lift, support, and bring the affected leg along in the
desired movement.

3. Communicate with the patient as much as possible.

Use gestures, facial expressions, and pantomime to
supplement and reinforce your message. Give short,
simple directions, and repeat as needed to ensure
understanding. Use concrete terms. If the patient
does not understand after repetition, try different
words. These are the general principles for patients
 who may not recognize or comprehend the spoken
word.

4. The underlying condition causing hypoxia must be

treated to manage and improve patient outcomes.

5. Monitor oxygen saturation level to manage

hypoxemic of the patient.

6. Continuously monitor V/S to watch out for

complications.

Dependent:

1. Administer oxygen as ordered by the

physician (2L/min) to increase blood oxygen
levels.

2. Administer isotonic saline as much as

possible.

3. Administer antihypertensive agents as

ordered by the physician’s order to treat
hypertension.

4. Initiate catheterization as ordered by the


Category II ORANGE
A 54 year old male admitted in ER with chief complaints
of severe chest pain that radiates from breast bone to left
arm up to his jaw. He stated that it started 2 hours ago. It
got worse and he is now experiencing shortness of breath
on slight activity. Vital signs are: BP 180/100, Temp 37.8
C, HR 102 bpm, RR 22 rpm, O2 saturation 86 %.
physician’s order to excrete urine from the
body and because the patient is unable to
move the left side of his body.
Justification:
The scenario given gives the ED nurse the idea that this is
the most priority case among the six. The patient
complained of severe chest pain and experiencing
shortness of breath with increased blood pressure, febrile,
increased respiratory rate and hypoxemia. Rule of thumb in
facility setting FIRST TO DIE, FIRST TO SEE. The overall
clinical manifestation would be the risk for heart failure.
This is life threatening, time sensitive treatment needed,
and must be seen within 10 minutes or else the conditions
might worsen.
Nursing Intervention with Justification:
Independent:
1. Assess character, and severity of the pain. Record
severity on a subjective 0 (no pain) to 10 (worst
pain) scale upon assessing the patient. It will help to
monitors degree, character, precipitator, and trend of
 pain for the initial check and subsequent
comparisons.

2. Assess HR and BP during episodes of chest pain.

Be alert to and report significant findings.Increases
in HR and changes in systolic blood pressure (SBP)
greater than 20 mm Hg from baseline signal
increased myocardial O2 demands and necessitate
prompt medical intervention.

3. Continuously monitor vital signs after giving this

medication for further assessment and conduction.

Dependent:

1. Can administer the medication such as: Nitrates,

Aspirin, Beta-blockers, and calcium channel
blockers.

Rationale:

> These medications block beta stimulation to the

sinoatrial (S-A) node and myocardium. HR, BP, and
contractility are decreased, subsequently reducing
workload of the heart and myocardial oxygen
demand, ultimately improving myocardial
oxygenation. Metoprolol may be administered IV as
the initial treatment.

> Administer sublingual NTG at the onset of pain (if

not on an IV NTG drip), and explain to the patient
that it is to be administered as soon as angina
begins, repeating q5min ×3 if necessary. NGT will

Category III ORANGE
Maine is a 62-year-old white female presented to the
emergency department with acute onset shortness of
breath. Symptoms began approximately 2 days ago. She
had similar symptoms approximately 1 year ago with an
acute, chronic obstructive pulmonary disease (COPD)
exacerbation requiring hospitalization. She reports
difficulty breathing at rest, forgetfulness, mild fatigue,
feeling chilled, requiring blankets, and swelling in her
bilateral lower extremities that are new-onset and
worsening. Subsequently, she has not ambulated from
bed for several days except to use the restroom due to
help increase microcirculation, perfusion to the
myocardium, and venous dilation.
> As prescribed, add IV morphine sulfate in small
increments (2 mg). Monitor HR, RR, and BP.
2. Obtain ECG as prescribed. ECG patterns may
reveal ischemia, as evidenced by dynamic ST- or
T-wave changes, evidence of new Q waves, or left
bundle branch block.
3. Administer O2 as prescribed. Hypoxia is common
because of the decreased perfusion and adds stress
to the compromised myocardium.
4. Deliver O2 with humidity. Humidity helps prevent
oxygen’s convective drying effects on oral and nasal
mucosa.
Nursing Intervention:
Independent:
1.) Monitor oxygen saturation levels. Breathing rate,
dept and patterns encourage deep breathing and
coughing.
2.) Placing the patient in a high fowler position to
enable breathing and instruct to cough and breath
and use supplementary oxygen equipment.
3.) Encourage fluid intake to make it easier to
expectorate.
feeling weak, fatigued, and short of breath. Vital signs: 4.) Monitor hemodynamically stable with a pericardial
temperature 36.8 C, heart rate 78 bpm, respiratory rate 28 effusion if possible.
cpm, BP 106/54mmHg, O2 saturation 89 % on room air. 5.) Monitor Input and Output
6.) Promote bedrest.
7.) Provide health teaching of the client’s case condition

Dependent:

1. Administer 02 therapy.

2. Give medications prescribed by the physician.

This scenario might a case of Ascites because of

Category IV GREEN abdominal swelling, confusion and weight gain, therefore
here are the possible nursing intervention as follows:
Presented to ER 48 y/o male with complaints of abdominal
swelling, with confusion, has weight gain of 15 pounds for Nursing Intervention:
the past 4 weeks, lethargic, acting strangely at the time of
assessment. Vital signs: BP = 140/90, P = 110/min
regular, RR = 22/min irregular, Temp = 37.8 C Independent:

1.) Inform the patient regarding his condition and to the

procedures that may be implemented to inform the
patient of his condition and procedure.
2.) Assess bowel movements (color, consistency,
frequency, amount). It is essential to report bowel
movement characteristics and frequency accurately.
 It also ensures accurate intake and output recording.
3.) Assess abdominal distention, report changes in size
and quality as appropriate. Patients may be
experiencing abdominal distention as part of the
underlying disease process.

4.) 24 hr urinary u.o if there is portal hypertension

manifested.

Dependent:

1.) Albumin infusion for every 5 liters of ascitic fluid to

decrease the possible complications such as
electrolyte imbalances and a like because if the
patient has an Ascites there is the possibility risk for
persistent hyponatremia which leads to inc.
creatinine levels.

2.) Abdominal CT scan as per physician’s order. It will

help to detect inflammatory conditions of the organ
in the abdomen.

Category V GREEN Upper GI is suspected therefore nursing intervention as

follows:

Washington is a 72-year-old woman who presented to the

emergency department who has been so sick for the past
few hours. She keeps on vomiting and has not been able
to keep anything down for the past three days. Upon
arrival at the ER, she vomited once and it was red like Nursing Intervention:
blood. She became nervous. Her skin is clammy and pale.
Vital signs are BP 110/50, HR 106/min, RR 22/min,
temperature 36°C. Independent:

1.) Assessment of the patient’s usual food intake and

food habits- falls under secondary assessment in
triage.

2.) Explain diagnostic tests and administer medications

on schedule to relieve the nervousness.

3.) Provide health teaching of the client’s case

condition.
4.) Continuously Monitor V/S to watch out for
complications.

Dependent:

1. Assessment of relief measures to relieve the pain

and medications as prescribed by the physician.

Category VI BLUE The case suggests Uremia because of diabetes and

hypertension that affects the renal function as manifested
Patient David is a 45 year-old male presented to ER who by pruritus and lethargic.
has a longstanding history of hypertension and diabetes
and presents with a complaint of pruritus, lethargy, lower
extremity edema, nausea and emesis. He denies any
other medical illnesses. Blood pressure 160/100, pulse
80/min, respirations 24/min and afebrile.
Nursing Intervention:
Independent:
1. Monitor the vital signs and watch out for further
complications.
2. Provide adequate rest to prevent fatigue.
3. Encourage patient to elevate lower limbs above the
level of the heart to help improve blood flow and
decrease swelling
4. Monitor Input and Output.
5. Limit NaCl and CHON intake. Salt restriction
reduces BP levels and enhances antiproteinuric
effect of renin–angiotensin–aldosterone system
inhibitor
6. Provide health teaching of the client’s case
condition.
Dependent:
7. Give medications as prescribed such as:
> antihypertensive agents to treat hypertension
> antiemetic drugs to stop vomiting.