EMERGENCY NURSING

PRACTICE IN
HOSPITAL FACILITIES
Triage
◦-derived from the French word trier, which
means, “to sort out or choose.”
◦Triage is the process of prioritizing which
patients are to be treated first and the
cornerstone of good disaster management
in terms of judicious use of resources (Auf
der Heide, 2000).
 Essential Personal Abilities to be an effective triage
officer. (Burke,1984)
◦

■ Clinically experienced
◦■ Good judgment and leadership
◦ ■ Calm and cool under stress
◦■ Decisive
◦ ■ Knowledgeable of available esources
◦ ■ Sense of humor
◦■ Creative problem solver
◦■ Available
◦■ Experienced and knowledgeable regarding anticipated casualties
When and where should triaging take
place?
◦ Triage should be carried out as soon as a sick patient
arrives, before any administrative procedure such as
registration.
◦ Triage can be carried out in different locations, e.g. in
the queue. Emergency treatment can be given wherever
there is room for a bed or trolley for the sick child,
enough space for the staff to work, and where
appropriate drugs and supplies are accessible
 Typical Information Elements Gathered at the
Point of Triage
● Name
● Age
● Gender
● Chief complaint (CC)
● History of present illness (HPI)
● Mechanism of injury (MOI)
● Past medical or surgical history (P M/S Hx.)
● Allergies to food or medication (Allergies)
● Current medications (Meds)
● Date of last tetanus immunization
● Last menstrual period (for females between the ages of 11and 60) (LMP)
●Vital signs: temperature, pulse, blood pressure, respiratory
●rate (VS)
●Skin vital signs (Skin vitals): temperature, color, moisture
●Level of consciousness (LOC)
●Visual inspection for deformities, lacerations, bruising,
●rashes, etc.
●Height and weight (pediatric patients) (Ht./Wt.)
●Mode of arrival (MOA)
●Private medical provider (PMD)
●Other
 TYPES OF TRIAGE PROCESS
1. Daily Triage

◦perform by nurse in the emergency room. It is a routine triage.

◦the goal is to identify the sickest patients in order to assess and provide treatment to them
first, before providing treatment to others who are less ill.

◦ The highest intensity of care is provided to the most seriously ill patients, even if those patients have
a low probability of survival
2. Incident triage

◦-occurs when the emergency department is stressed by a large number of patients but is still
able to provide care to all victims utilizing existing agency resources.

◦-Additional resources (on-call staff) are used, but disaster plans do not have to be activated.

◦-The highest intensity of care is still provided to the most critically ill patients. Emergency
department delays may be longer than normal, but eventually everyone who presents themselves
for care is attended to.
1. Disaster triage

◦employed when local emergency services are overwhelmed to

the point that immediate care cannot be provided to everyone who
needs it.

◦The goal of triage now shifts to identifying injured or ill patients

who have a good chance of survival with immediate care that does
not require extraordinary resources (Auf der Heide, 2000).

(a) Critical

◦ Critical casualties are those that are life threatening, but

likely to be amenable to rapid intervention that does not require an
inordinate amount of resources.
(b) Urgent

◦ conditions that are serious and, if not treated in a timely manner,

are likely to deteriorate to become critical.

(c) Minor

◦care required can be provided in a low-tech setting and a delay in

treatment would unlikely contribute to a significant deterioration in the
victims’ condition.

(d) Catastrophic

◦ conditions that have either a very grave prognosis or would require an

amount of resources that are so large they would divert care from
others with a much better prognosis.
 In-hospital Triage Systems
◦ Most hospitals utilize a triage system that has between three and five
categories.
1. Three-tier system,

• Emergent -signifies a condition that requires treatment immediately or within 15 to 30

minutes.

◦ Urgent - utilized for serious illness or injury that must be attended to, but can wait of
up to 2 hours would not add to the morbidity or mortality of the patient.

• Nonurgent - can wait more than 2 hours to be seen without the likelihood of
deterioration.

2. Four-tier system

◦The emergent category is subcategorized to identify those conditions that must be

treated immediately (stat or 1A) versus rapidly (within a few minutes or 1B).

3. Five-tier system

◦nonurgent category is subcategorized as nonurgent-ED and nonurgent

 Basic Differences Between Daily and
Disaster Triage
CIVILIAN TRIAGE DISASTER TRIAGE
- Most fragile patients are identified - Fragile patients who have a good
and treated first likelihood of survival and do not
- Divided into two types: usual require an extraordinary number of
hospital daily triage and disaster resources are treated first.
situation triage. - Disaster triage is similar to tactical
- Tend to collect more information at military triage in that the goal is the
the point of triage greatest good for the greatest
number of injured.
- The number of data collected during
the initial triage encounter may be
reduced
 Daily Triage in the Hospital Setting
◦The sickest patients are given priority.
◦When a hospital receives a large number of cases, additional
staff and resources are brought to the emergency department
◦ If a hospital’s capacity is likely to be overwhelmed, patients
are diverted to other institutions.
◦In this type of triage, patients with an airway, breathing, or
circulation emergency are assigned the highest degree of
urgency and receive care first.
 Disaster Triage in the Hospital Setting
1. Hospitals and their emergency departments usually activate their receive
an additional influx of patients.
2. To eliminate delay of time required to enter the disaster victim into the
system disaster, Stat charts should be prepared ahead of time along
with a prestamped triage slip, identification band, and lab and X-ray
requisition slips so a patient can be immediately assigned a medical
record number as they enter the ED.
3. As patients arrive at the emergency department triage area, they are
issued a STAT pack and entered onto the disaster patient tracking log
4. Diagnostic testing can be performed without waiting for an actual
registration in the hospital information system.
5. As the patients enter the emergency department triage team staff should
be stationed at the ambulance bay
Contents of Typical STAT Pack
Chart System
Staff Complement of a Typical
Disaster Triage Team
 Disaster Triage in the Hospital
Setting
◦ As the patient arrives, the triage team does a rapid triage evaluation,
while a clerk applies a stat record identification band, hands the
corresponding triage slip to the triage officer, places the stat chart on the
stretcher with the patient, and logs the stat medical record number, stat
name number, and, if possible, the patient’s name and emergency
department area assignment.
◦ As a patient is stabilized and leaves the emergency department, and
after the rapid assessment, the patient is triaged to a treatment location
and team in the emergency department (or other designated area in the
facility), where a more thorough evaluation and assessment will take
place.
 PATIENT ASSESSMENT IN EMERGENCY
DEPARTMENT
INITIAL ASSESSMENT
PRIMARY PHASE (ABCDE APPROACH)
◦ A– Airway: check for and correct any obstruction to movement of air into the lungs.
◦ B– Breathing: ensure adequate movement of air into the lungs.
◦ C– Circulation: evaluate whether there is adequate perfusion to deliver oxygen to the tissues; check
for signs of life-threatening bleeding.
◦ D– Disability: assess and protect brain and spine functions.
◦ E– Exposure: identify all injuries and any environmental threats and avoid hypothermia.
SECONDARY PHASE (FGHI)
Done after primary exam and primary threats addresses

◦ -Measurement of vital signs

◦ -Pain assessment
◦ -History Taking
◦ -Head to toe assessment (Cephalocaudal)
◦ -Posterior surface inspection
 FULL SET OF VITAL SIGNS (F)
◦ Vital signs- The vital signs must include the following parameters:
● Temperature (36.5 to 37.5°c)
◦ -Oral, Tympanic, Temporal Axillary or Rectal
● Pulse (Adult 60-100 bpm, Pedia 80 to 120 bpm, Newborn 100-160 bpm)
◦ -Rate and Rhythm (Regular or Irregular)
◦ -Quality (Weak, Thready, Bounding)
● Respiratory Rate -Rate, Rhythm, Depth and WOB
● Blood Pressure Proper size of cuff is important
● Oxygen Saturation Proper placement of probe is key
● Weigh Must be done to all children/infants
 GIVE COMFORT MEASURES (G)
◦ Pain= "the 5th vital signs"
◦ Medical Patient- Questions to ask:
◦ OPQRST
-Pain Scale 0-10
◦ -FACES pain scale
◦ -FLACC infant pain scale
HISTORY(H)

◦ SAMPLE history- Basic Questions to ask all patients:

◦ S-Signs/symptoms?
◦ A-Allergies?
◦ M-Medications?
◦ P-Pertinent past medical history?
◦ L-Last oral intake?
◦ E-Events leading to illness or injury?
Inspect Posterior Surface (I)
◦ Head and Neck
◦ Inspect
- Laceration, abrasion, puncture wound, burns, foreign objects, rash
- Oral mucosa hydration, swelling, bleeding, loose teeth
- Eyes(PERRLA), eyelids, vision status
◦ Palpate
- Feel for broken bones, asymmetry and tenderness
ASSESSING MENTAL STATUS

◦A-Alert: awake and oriented

◦V-Verbal: responds to verbal stimulus
◦P-Painful: responds to painful stimulus
◦U- Unresponsive
Neck

◦ Inspect
- Injury, deformity, rash, lesion and masses
- Jugular veins
◦ Palpate
- Areas of tenderness
Chest (Pulmonary and Cardiac)

◦ Inspect
- Rate and depth of respiration, trauma, rash or lesion,
pacemakers, medication patches etc.
◦ Palpate
- Bony deformity, crepitus and tenderness
◦ Auscultate
- Lung sound, adventitious sounds and heart sounds
Abdomen

◦ Inspect
- Contour of abdomen, ascites, trauma, scars, tubes, stomas
◦ Palpate
- For rebound tenderness
◦ Auscultate
- Bowel sounds
Pelvis/Perineum

◦Inspect
- Trauma, edema, lesion, bleeding,
drainage or discharge(and quantity)
◦Palpate
- Pelvis bony stability
Extremities

◦Inspect
- Lesion, redness, edema, rash, trauma, wound
and movement
◦Palpate
- Tenderness, pulse,pain, capillary refill, sensation