10/30/2018 1Instructor/ Amparo Sanchez.
• Triage began with the military during World War I.
• Is a French word that emphasizes the context of sorting,(classification) or sifting.(examination) .
• Is a organized system for classifying pts into priority levels.
• Prioritization of care based on illness/ injury, severity, prognosis, and resource availability.
• Identifies patients who cannot wait to be seen, prioritizes all patients, and initiates diagnostic and therapeutic measures.
10/30/2018 2Instructor/ Amparo Sanchez.
• Triage is the first assessment in patient care.
• The RN is the member assigned to perform the triage function in most hospitals. In coordination with professional staff who function in support roles.
10/30/2018 3Instructor/ Amparo Sanchez.
Triage • As the healthcare system evolved,
Emergency Departments (ED) became an important source of care for the community, structured through triage principles.
• The demand for emergency care in US is growing rapidly.
• ED function as safety nets for communities, providing services to each people seeking medical care.
• The emergency nurse is one member of the large interdisciplinary team.
10/30/2018 4Instructor/ Amparo Sanchez.
• The triage area in most facilities serves as the front door of the hospital.
• This area is where life and death decisions are made, and these decisions are based on the knowledge and experience of this trained ED triage nurse .
• The assessment process must be rapid and systematic utilizing age- specific considerations.
• The triage process should be completed in less than five minutes.
10/30/2018 5Instructor/ Amparo Sanchez.
Triage.Training and Certifications for E.Nursing
BLS Basic Life Support. Required
ACLS Advanced Cardiac Life Support, usually required.
PALS Advanced Cardiac Life Support, may required.
CEN Certified Emergency Nurse (optional)
Noninvasive assessment and management skills for airway maintenance and CPR.
Invasive airway management skills, pharmacology, and electrical therapies, special resuscitation.
Neonatal and Pediatric Resuscitation.
Validates core emergency nursing knowledge base. 6
• Emergency department triage differs from Disaster triage.
• During a disaster with limited resources, patients with little or no chance of survival are not resuscitated.
• Key to effective management of the injured, especially when multiple victims are present,
• Is the ability for rapid identification of those individuals who most need and can best benefit from the limited available care.
10/30/2018 Instructor/ Amparo Sanchez. 7
• Supervisors will initiate the disaster plan and designate task to workers, in coordination with multidisciplinary staff, EMS, paramedics, transports, stretchers etc. The worker is responsible to:
• Locate the disaster plan on each unit where he/she works
• Know the alarm codes for each type of disaster
• Know the exit routes
• Know how to use any evacuation equipment
• Know Triage Systems
10/30/2018 8INSTRUCTOR : AMPARO SANCHEZ
As with other aspects of nursing, triage has rights.
• The four rights of triage include: Getting the right:
• Following the four rights will always lead to accurate triage.
10/30/2018 9Instructor/ Amparo Sanchez.
10/30/2018 Instructor/ Amparo Sanchez. 10
• The focused triage Assessment of the presenting complaint must be done by an experienced nurse to help differentiate between possible diagnoses.
• The experienced triage nurse must be able to anticipate these diagnoses in order to make the proper disposition of the patients.
10/30/2018 11Instructor/ Amparo Sanchez.
Assessment. • A focused physical assessment will be performed depending on
the chief complaint.
• Mental status, skin temperature, moisture and color of mucous membranes will be assessed in addition to the focused physical exam. A past medical, surgical, psychiatric and family history will be ascertained.
• Current medications and dosages including OTC and herbal/natural remedies will be documented. Treatment prior to triage.
• Vital signs will be recorded as appropriate including pulse oximetry and pain scale.
• For example, touching the patient tells the nurse:
• Temperature , Moisture , Regularity or irregularity of the pulse.
• The quick head to toe assessment in the process of performing the focused assessment also tells the nurse if there are signs of abuse or neglect and other problems that could be associated with the primary complaint.
10/30/2018 12Instructor/ Amparo Sanchez.
1.Assessment. Chief complaint and history of present illness/ injury
• Triage begins with a general assessment of the patient.
• Aspects of triage include obtaining: • Major threats to the airway, breathing,
and circulation will be assessed and the nurse will provide immediate interventions for identified threats and /or transport the patient to the appropriate treatment area, assures the proper disposition of the patient.
• A history of the patient’s presenting symptoms, a medical history of the patient, and completing an assessment that is based on the presenting complaint.
10/30/2018 13Instructor/ Amparo Sanchez.
Assessment. • The history of the present illness/injury will be
determining onset, duration, provoking/alleviating factors, mechanism of injury and accompanied signs and symptoms.
• If pain is the chief complaint; severity (pain scale), quality and radiation of the pain will also be ascertained.
• History will be obtained from EMS personnel, police, family or witnesses if available in the unconscious/unresponsive patient.
• When performing the triage assessment, the triage nurse must actually lay hands on the patient and perform a quick head to toe assessment while focusing on the presenting complaint.
• Much information can be obtained when executing the triage assessment in this manner.
10/30/2018 14Instructor/ Amparo Sanchez.
Assessment. • Last menstrual period for women of
child bearing age. Ask female patients about their menstrual cycle.
• Immunization. • Current weight for patients <18 years
of age. • While completing the history, the
triage nurse should determine if the patient has any allergies to drugs or foods.
• Make sure to ask about the onset of symptoms.
10/30/2018 15Instructor/ Amparo Sanchez.
• As with any patient, addressing the ABCDs are the primary concern, but determining the disability of the patient aids the triage nurse in upgrading any triage disposition decision.
• Therefore, observing the patient and doing a visual survey is the first step in the process.
10/30/2018 16Instructor/ Amparo Sanchez.
• Assessing the airway, breathing, circulation, and disability.
• All patients are assessed for abuse/ neglect. (domestic violence, child abuse/neglect ,elder abuse/ neglect and sexual assault)
10/30/2018 17Instructor/ Amparo Sanchez.
• Screening the patient for signs and symptoms of tuberculosis (TB) occurs in triage to prevent further spread and exposure.
• Make sure to ask the patient if he/she has had recent unexplained weight loss, night sweats, fever, or coughing.
10/30/2018 18Instructor/ Amparo Sanchez.
2.Guidelines for the focused physical assessment:
Examples of complaints are provided. 1.Cardiopulmonary:
Breath sounds, peripheral edema, peripheral pulses Examples; chest pain, shortness of breath, dyspnea on exertion, weakness, lightheadedness.
2. Neurological: Pupil size and reactivity, speech quality, facial symmetry, motor strength and equality and Glasgow coma scale, fingerstick. Examples; change in mental status, seizure, headache, dizziness, difficulty in walking, speaking or moving, head or neck trauma.
3. Abdominal/pelvis: Inspection, palpation, guarding, rebound, referred pain, rigidity CVA tenderness, pulsatile masses, breath sounds, last meal, last bowel movement. Examples:abdominal pain, nausea, vomiting, diarrhea, abnormal bowel movements, constipation, difficulty or pain on urination, hematuria, vaginal bleeding, trauma.
10/30/2018 Instructor/ Amparo Sanchez. 19
2.Guidelines for the focused physical assessment:
4. Neurovascular: Color, temperature, pulses, capillary
refill, motor/sensory status. Examples: extremity pain, edema or trauma, cast check, back pain.
5. Hypovolemia: Estimate blood/fluid loss,
orthostatic vital sign changes. Examples: external hemorrhage, vomiting, diarrhea, vaginal bleeding, blood in stool, hematuria, major trauma.
6. Trauma/wound evaluation depends upon mechanism of injury. Major trauma may require head to toe exam.
10/30/2018 Instructor/ Amparo Sanchez. 20
2.Guidelines for the focused physical assessment:
7. Ear or throat: Hearing loss, oral cavity edema, edema to lips. Examples; ear pain, throat
pain, pain on swallowing, difficulty in swallowing, foreign body. 8. Opthamological: Visual acuity, sclera color, conjunctiva color, pupil equality and reactivity,
ocular movements. Examples; eye pain, vision loss, vision abnormalities, foreign body, trauma.
9. Skin: Color, description of rash, urticaria, lice, scabies, wounds (lacerations,
contusions, avulsions, skin tears) Examples; pain, itching, rash bumps on skin.
10. Obstetrical: Fetal heart rate, crowning. Examples; water broke, in labor, abdominal
pain,vaginal bleeding, baby is not moving, trauma. 11. Psychiatric: Assess need for constant observation, affect, and hygiene. Examples;
hallucinations, anxiety, depressed, suicidal/homicidal ideations
References.Triage Curriculum 2nd Edition, Emergency Nurses Assn. 2001
Instructor/ Amparo Sanchez.
3.Maintaining pts and staff safety in ED Safety considerations Interventions to minimize risks.
Patient identification. Provide an identification (ID) bracelet for each patient. Use two unique identifiers (e,g, name, date of birth. If pt identity is unknown, use a special identification system or institutional polices (“Jane /John Doe”)
Injury prevention for pts. Keep rails up on stretcher. Maintain stretcher in lowest position. Call light for assistance. Reorient confuse pt frequently. If confused ask family member or other to remain with him or her. Implement measures to protect skin integrity
10/30/2018 Instructor/ Amparo Sanchez. 22
Maintaining pts and staff safety in ED Safety considerations Interventions to minimize
Risks for errors and adverse events Obtain pt and family history. Check medical alert, bracelet or necklace. Search pts belongings for weapons or harmful devices if the pt has altered mental status.
Injury prevention for staff. Use Standards Precautions all time. Anticipate hostile, violent pt, family and or visitor behavior. Plan options if violence occurs, including assistance from the security department.
10/30/2018 Instructor/ Amparo Sanchez. 23
SOAPIE SOAPIE stands for: • Subjective data (chief
complaint); • Objective data such as vital
signs; • Analysis of data, leading to
assigning acuity; • Plan, or what is to be done; • Initiating diagnostic/therapeutic
interventions per protocols and nursing practice;
• Evaluation, which indicates that triage is a dynamic process with constant evaluation and re- evaluation.
10/30/2018 Instructor/ Amparo Sanchez. 24
Question 1 The 30-year-old female that arrives in triage with a chief complaint of abdominal pain, she has bruises in various stages of healing and is accompanied by her boyfriend. Place the nurse consideration that must takes. Select all apply.
A. Must be assumed to be pregnant until proven otherwise.
B. At this point it would be imperative to separate the girlfriend and boyfriend.
C. Determine if the bruises were a result of abuse by the boyfriend.
D. Assumed that she would not discuss the abuse if the boyfriend were present in the room.
E. If abuse is suspected by the nurse, or abuse is reported by the patient, the nurse is not obligated to report this
10/30/2018 25Instructor/ Amparo Sanchez.
Triage Nurse Qualifications
• The Emergency Nurses’ Association (ENA) recommends that the triage nurses have a minimum of six months
10/30/2018 26Instructor/ Amparo Sanchez.
Two factors to keep in mind when triaging patients:
• All chest pain is considered cardiac until proven otherwise
• All women of child bearing age are considered pregnant until proven otherwise.
10/30/2018 27Instructor/ Amparo Sanchez.
Vital signs, should be taken including Pain assessment.
• Description of pain including the PQRST.
10/30/2018 28Instructor/ Amparo Sanchez.
• T= Time
10/30/2018 29Instructor/ Amparo Sanchez.
A = allergies, age
M = medications
P = past history
L = last meal, tetanus, menstrual period
E = events of the illness or complaint –
10/30/2018 Instructor/ Amparo Sanchez. 30
• Once the initial triage assessment is completed and the disposition decision is complete, the triage nurse must monitor those patients sent to the waiting room.
• These patients will need reassessment during their stay in the waiting room.
10/30/2018 31Instructor/ Amparo Sanchez.
10/30/2018 Instructor/ Amparo Sanchez. 32
• Nursing Priorities: • The RN must triage all her clients to
prioritize the order of assessments and care delivery.
• Maslow’s Hierarchy of Needs should be remembered! Critical thinking will help the RN establish which needs are urgent versus non-urgent.
• Priority questions are tricky! As you read each possibility, ask yourself what can happen if care to that client is delayed.
• You may also need to look at the probability that any given client may deteriorate.
10/30/2018 33Instructor/ Amparo Sanchez.
10/30/2018 Instructor/ Amparo Sanchez. 34
Priorities.Resuscitation Interventions Primary Survey Interventions
A: Airway / Cervical Spine
Always assume all major trauma patients have an injured spine and maintain spinal immobilization until spine is cleared. Establish a patent airway by positioning, suctioning, and O2 as needed. Check the resuscitation equipment and prepare intravenous lines and fluids. Use a jaw-thrust maneuver if there is a risk for spinal injury. If the Glasgow Coma Scale(GCS) is 8 or less or if the pt is a risk for airway compromise, prepare for endotracheal intubation and mechanical ventilation.
B: Breathing R < 8 > 24 R/min.
Assess breathing sounds and respiratory effort. observe the chest wall trauma or other physical abnormality. Prepare for chest decompression if needed. Prepare for assist ventilation
10/30/2018 Instructor/ Amparo Sanchez. 35
Resuscitation Interventions Circulation Assess the circulatory state by observing:
pulse rate, skin colour, capillary refill time, blood pressure; the effects of an inadequate circulation (respiratory rate, mental state). Establish intravenous access with large bore cath. As the IV is inserted, take blood for a blood sugar, FBE, cross-match. If circulation is inadequate, give a fluid bolus of 20 ml/kg of normal saline. Use direct pressure for any continuing external haemorrhage.
Disability (mental state) Assess mental state by determining the LOC, GCS. Reevaluate the LOC frequently. Response to a painful stimulus, observing
his/her posture, and examining the pupillary reflexes. (e.g. flexion of one arm and extension of legs
is recorded as flexion to pain). 10/30/2018
Instructor/ Amparo Sanchez. 36
Exposure Removing all clothing for a complete physical assessment. Prevent hypothermia, eg. Cover the pt with blankets, use heating devices, infuse warm solutions
10/30/2018 Instructor/ Amparo Sanchez.
See A B C D A client with breathing problems
A client in danger of serious bleeding, such as a post-op client.
The Nurse must ensure the client’s state has not changed before the surgery. Must prepare the client for surgery and must note that the physician has obtained an informed consent.
A client headed to surgery within hours will have priority over stable clients.
Call bells must be in reach with extra monitoring for clients who cannot use the call light. Clients must be checked every 30 minutes.
10/30/2018 38Instructor/ Amparo Sanchez.
Question 2 • A trauma client has been brought to the ED after
a motor vehicle crash. The client has severe injuries. What action does the nurse perform first?
• A. Star a large bore catheter IV and run NS
• B.Apply O2 and an oximeter probe to the client
• C. Stabilize the cervical spine and assess the airway.
• D. Place pressure on a large bleeding wound to the forehead
10/30/2018 Instructor/ Amparo Sanchez. 39
10/30/2018 Instructor/ Amparo Sanchez. 40
Age can be one of the biggest barriers. • The very young and the older
individuals generally present the most difficulty for the inexperienced nurse.
• The pediatric patient’s vital signs must not be forgotten.
• Knowing the normal ranges for children is vital to making disposition.
10/30/2018 41Instructor/ Amparo Sanchez.
Pediatric Triage • The triage nurse must adjust the approach and
assessment based on the chronological and emotional age of the child.
• Children have feelings and emotions just as adults do and are perfectly capable of expressing themselves.
• The pulse of the infant would be assessed at the brachial artery rather than at the radial artery.
• Assessing respiratory quality, rate, and effort would be the same in both children and adults.
• With pediatric patients, the assessment should begin with the chest and abdomen.
10/30/2018 42Instructor/ Amparo Sanchez.
Triage Categories and Triage Systems for Pediatric Patients
• Various acuity systems for specific diseases, illnesses, and injuries in pediatric patients have been developed.
• Multiple pediatric trauma scoring systems exist.
• Scoring systems for specific respiratory diseases, such as “Croup Scores,” have also been developed.
• Various scales for assessment of the young infant with fever, observational scale, have been used to specific call evaluate the febrile infant.
10/30/2018 Instructor/ Amparo Sanchez. 43
Triage Categories and Triage Systems for Pediatric Patients
Range of pediatric age groups:
• (newborns, infants, toddlers, preschool age, early school years, and adolescence) has yet to be developed and validated in extensive numbers of pediatric patients.
10/30/2018 Instructor/ Amparo Sanchez. 44
Pediatric triage • Pediatric triage and/or assessment tools are
available. • A commonly used triage acuity classification
for pediatric patients uses four levels:
Class 1: Critical: life- or limb-threatening illness/injury that needs immediate care Class 2: Acute: significant alteration in physical or mental health that could potentially become life or limb threatening and needs intervention as soon as possible Class 3 : Urgent: significant physical or mental health problems that are not life threatening and need intervention in a timely fashion Class 4: Nonurgent: may receive care when convenient
These are similar to the adult four-level acuity classifications. • More recently, a five-level system has been
suggested, again similar to the adult five-level acuity classifications
10/30/2018 Instructor/ Amparo Sanchez. 45
SAVE-A-CHILD GUIDE A pediatric triage mnemonic— “SAVE-a-CHILD”—was designed to aid in recognizing a seriously ill pediatric patient. SAVE stands for the:
S Skin: Mottled? Cyanotic? Petechiae? Pallor?
A Activity: Needs assistance/ Not ambulating? Responsive?
V Ventilation: Retractions? Head bobbing? Drooling? Nasal flaring? Slow rate? Fast rate? Stridor? Wheezing?
E Eye Contact Glassy stare? Fails to engage/ focus? SAVE is based on observations made before touching the child.
10/30/2018 Instructor/ Amparo Sanchez. 46
SAVE-A-CHILD GUIDE A pediatric triage mnemonic— “SAVE-a-CHILD The “CHILD” component stands for: A Abuse : Unexplained bruising/ injuries? Inappropriate parent?
C Cry : High pitched, cephalic? Irritable? H Heat: High fever (>41°)? Hypothermia (36°)? I Immune System: Sickle cell? AIDS? Corticosteroids? L Level of Consciousness : Irritable? Lethargic? Pain only? Convulsing? Unresponsive?
D Dehydration: Hollow eyes? Capillary refill? Cold hands, feet? Voiding? Severe diarrhea? Vomiting: projectile, bilious, persistent? Dry mucous membranes?
This information is obtained from the parent (or caregiver) and a brief examination
10/30/2018 Instructor/ Amparo Sanchez. 47
Older adult triage
• Older people’s assessment and management in the ED can be complex, time consuming, and require specialist skills, because of worsening of an existing chronic condition.
• Assessment of cognitive impairment, functional problems, and existing home care must be seen as essential information for older adults in the ED.
10/30/2018 Instructor/ Amparo Sanchez. 48
Older adult triage • Assessment of
cognition, continence, medication, mobility problems, postural instability, and visual impairment.
• This is in addition to screening for potential medical explanations for falls such as causes of syncope.
10/30/2018 Instructor/ Amparo Sanchez. 49
Older adult triage • Fall is a fractured neck of
femur, and older adults with frailty can have high mortality rates.
• A hip fracture must be rapid identification, and management of potentially treatable comorbidities, such as anemia, hypovolemia, and electrolyte imbalance, to permit emergency surgery as early as possible.
10/30/2018 Instructor/ Amparo Sanchez. 50
Older adult triage • The elderly, a fall may result as
a consequence of underlying illness such as sepsis, cardiac causes, or medication changes
• Some of the most common reasons that older people seek ED care are:
• Confusion, Fatigue, Weakness . • UTI • Abdominal pain • Chest pain( MI) • Breathing
difficulties(Pneumonia, COPD) • Injuries (especially falls and
the incidence of fracture in this group is as much )
• Depression • Pain (most common symptom)
10/30/2018 Instructor/ Amparo Sanchez. 51
Question 3 The Emergency department Nurse is assigned to four clients waiting for orders to be implemented. Which client does the nurse assess first?
• A. 60-years -old waiting for transport to the operating room for an emergency appendectomy.
• B. 25-years- old with a closed femur fracture who received pain medication 10 minutes ago
• C.30-years –old with nausea and vomiting who has iv fluids infusing and is now sleeping
• D. 20-years-old construction worker with a laceration to the arm that is waiting to be sutured
10/30/2018 Instructor/ Amparo Sanchez. 52
Question 4.Older adult triage A 78-year-old man has generalized aching, headache, and fatigue. On further questioning, he reports hearing loss and urge incontinence. He also has lost interest in his weekly golf game. Which of the following should you do next?
(A) Evaluate each complaint individually
(B) Ask the patient which symptom bothers him most and evaluate it first
(C) Evaluate the possibility of depression.
(D) Perform a comprehensive geriatric assessment
(E) Validate the patient’s complains with a close family member or friend
10/30/2018 Instructor/ Amparo Sanchez. 53
Question 5.Older adult triage • An 80-year-old woman must use her arms to rise
from a chair. Her balance is good and gait is normal. Findings of the remainder of physical examination are unremarkable. The patient has been less active in the past 2 months; she used to take daily walks but stopped because of inclement weather. Which is the best initial management for this patient?
(A) Referral for physical therapy
(B) Raised toilet seat
(C) Single-point cane
(D) Increased exercise.
10/30/2018 Instructor/ Amparo Sanchez. 54
10/30/2018 Instructor/ Amparo Sanchez. 55
10/30/2018 Instructor/ Amparo Sanchez. 56
10/30/2018 57Instructor/ Amparo Sanchez.
Simple Triage and Rapid Treatment (START) system.
• Use rapid assessments, under one minute per victim, and colored, highly visible priority tags to minimize confusion at the scene.
• The START system categorizes patients into four groups:
• Green .
10/30/2018 58Instructor/ Amparo Sanchez.
Four color groups.
Red (Immediate): • Patients are critically injured, with problems that will require immediate intervention to correct .
(immediate) patients have an immediate threat to life or limb but, if given immediate care, will probably survive. First priority and are “most urgent Examples include a patient with altered mental status, labored respirations, or shock.
Yellow • (Delayed): Patients are injured and will require some medical attention, yet will not die if care is
delayed for other patients. Individuals placed in this category have respirations under 30 per minute, capillary refill of less than 2 seconds and can follow simple commands. Yellow patients are not ambulatory and will require a stretcher for transportation (delayed) patients have signifi cant injuries but can probably tolerate a 45- to 60-minute wait without undue risk.
Green, Minor or Ambulatory: • Patients are not critically injured and can walk and care for themselves, but they require minor
treatment . Casualties who are ambulatory are asked to move away from the immediate area of the incident. These “walking wounded”
Black: • Patients, are deceased or have such catastrophic injuries that they are not expected to survive
transport . Unsalvageable patients are patients who are not breathing even after positioning their airway and are classified “black” or deceased.
10/30/2018 59Instructor/ Amparo Sanchez.
10/30/2018 Instructor/ Amparo Sanchez. 60
TRIAGE /Five level
• The five level triage system has proven to be the most effective and provides the triage nurse with more accuracy and consistency for the triage process.
• The ENA (Emergencies Nurses Association)adopted and promoted the five level triage system in 2002.
• Demonstrates assessment criteria and nursing considerations for each level.
10/30/2018 61Instructor/ Amparo Sanchez.
ENA/ LEVELS Acuity/Assessment Level Nursing Considerations
Level 1-Critical Resuscitation
Level 2-High Risk Emergent
Level 3-Moderate Risk Urgent
Level 4-Low Risk Semi or less Urgent
Level 5-Lower Risk Non Urgent
10/30/2018 62Instructor/ Amparo Sanchez.
10/30/2018 Instructor/ Amparo Sanchez. 63
10/30/2018 Instructor/ Amparo Sanchez. 65
10/30/2018 Instructor/ Amparo Sanchez. 66
4.- LESS URGENT
10/30/2018 Instructor/ Amparo Sanchez. 67
5.- NON URGENT
10/30/2018 Instructor/ Amparo Sanchez. 68
• Artificial ventilation required • Absent or diminished breath
sounds • Oxygen saturation <90% • Apnea • Unable to speak • Significantly orthostatic • Unable to control active
• Hemodynamically unstable • Requires electrical therapy
such as defibrillation • Bradycardia in a pediatric
patient • Pulseless • Non-responsive • Symptomatic severe
hypotension • Central cyanosis
10/30/2018 69Instructor/ Amparo Sanchez.
Level 2. • Acute respiratory distress not
requiring artificial ventilation • Upper airway no complete
• Potential to decompensate
• Toxic or smoke inhalation
• Facial burns with burned nasal hairs
• Unable to speak in complete sentences
• Oxygen saturation <94%
• Severe stridor • Moderate use of accessory
muscles • Acute chest pain • History of angioplasty and chest
pain • Persistent chest pain after
nitroglycerin dosing • Severe chest pain
• >35 y.o. with palpitations
• Drug abuse in last 24 hours
10/30/2018 70Instructor/ Amparo Sanchez.
• Wheezing onset within past two hours, normal VS
• Frothy sputum • Tight cough • Recent chest pain • Positive orthostatic VS (15
point difference in SBP or HR with position change)
• VS within normal limits • <35 y. o with palpitations
• Family history of heart disease
• Moderate pain • Stable rhythm
10/30/2018 71Instructor/ Amparo Sanchez.
• COPD, having increased cough or shortness of breath and oxygen saturation >88% • Symptoms consistent with pharyngitis
• Speaking in full sentences • Fever >103 F
• Productive cough • > 60 y.o. with fever > 101 F
• Recent injury
• Fever, cough and congestion.
10/30/2018 72Instructor/ Amparo Sanchez.
• Non productive cough
• Cold or flu symptoms
• Oxygen saturation >95%
• Reproducible chest pain • Pain increases with breathing or coughing • Chronic pain.
10/30/2018 73Instructor/ Amparo Sanchez.
Questions 6. Place ER or UC or NU in each case
1. Sudden excruciating headache.______
2. Loss of feeling on one side of the body. ______
3. Chest pain. _____
4. Severe bleeding._____
5. Ear infections _______
6. Simple burns or cuts_____
7. Eye injuries_______
10/30/2018 Instructor/ Amparo Sanchez. 74
Questions 7. Triage the following pts. Place in order of priority each case.
1. Sprains and strains
2. Colds, flu
3. Allergic reactions
4. Head trauma.
5. Loss of consciousness.
6. Sudden blurred vision or loss of vision.
• ___ ___ ____ ___ ____ ___
10/30/2018 Instructor/ Amparo Sanchez. 75
Question 8.Identify: Pts Emergent(E), Urgent,(U) Non Urgent (NU),Fill in the blank
1.Open fracture ________ 2.Extremity injury with severe deformity or neurovascular
compromise (decreasing pulse, sensation or movement)_______
3.Laceration with uncontrolled bleeding.______ 4.Neck pain secondary to trauma<48hour or associated with
stiff neck._______ 5.Pain beneath existing cast without neurovascular
compromise 6.Laceration with controlled bleeding.________ 7.Closed fracture suspected without deformity or
neurovascular compromise._________ 8.Back pain secondary trauma in last 72 hours.________
10/30/2018 Instructor/ Amparo Sanchez. 76
Question 9.Identify the priority order. Triage the following Pts.
1. Patients who are having hallucinations.
2. Burns with>10% TBS, burns of the face ,hands, genitalia and foot. Child age 1 year.
3.Pain beneath cast with neurovascular compromise (compartment syndrome)
4. Burns with < 20 % TBS. Male 25 year-old. Burns in right leg circumferential.
10/30/2018 Instructor/ Amparo Sanchez. 77
Quest.10.Identify: Pts Emergent(E), Urgent,(U) Non Urgent (NU),Fill in the blank
1.Sprain/bruises without obvious deformity.______
2.Extremity pain without neurovascular compromise._______
3.Chronic back pain.______
4.Minor injury greater than 72 hours old.______
5.Wound check, suture removal.________
6.Respiratory symptoms with no acute distress ____
8.Cold symptoms sore throat , runny nose._______
10/30/2018 Instructor/ Amparo Sanchez. 78
• Emergent: • Pelvic pain and change in
vital signs or severe pelvic pain alone.
• <20 weeks pregnant , profuse bleeding.
• Prolapsed umbilical cord. • >20 weeks gestation with
abdominal pain /labor or vaginal bleeding.
• Rape /sexual assault. • Heavy post-partum
bleeding (vital sign )
10/30/2018 Instructor/ Amparo Sanchez. 79
URGENT : • Pelvic pain over 48 hours,
vital are normal. Bleeding(not profuse) <20 weeks pregnant.
NON-URGENT • Vaginal discharge, rash or
itch. • Suspected pregnancy. • Suspected venereal disease. • Breast lump. • Non-profuse vaginal
bleeding not related to pregnancy.
• Chronic pelvic pain (over two weeks)
• Menstrual cramps.
10/30/2018 Instructor/ Amparo Sanchez. 80
10/30/2018 Instructor/ Amparo Sanchez. 81
Resources. Resources are not counted individually. For example: • Labs constitute one resource,
therefore a complete blood count (CBC), a basic metabolic panel (BMP), and prothrombin time (PT) on the same patient would be counted as one (1)resource instead of three.
• If the provider adds a chest x-ray, the resources just increased to two (2) and therefore the triage category just advanced to a minimal three. (3)
10/30/2018 82Instructor/ Amparo Sanchez.
• In the triage category three (3), the triage nurse then must look at the VS and determine if they are within the normal ranges.
• If the VS are normal, the patient remains a category three.(3)
• If the VS move outside the normal range,abnormal or subnormal, the patient’s triage classification advances to a category two.(2)
10/30/2018 83Instructor/ Amparo Sanchez.
Examples of resources
Examples of Resources
• Labs • X-Rays, CT, US • EKG • Medications (IV, IM, nebulizer) • Procedures • Consults
10/30/2018 84Instructor/ Amparo Sanchez.
Examples of non-resources
• Not Considered to be Resources
• • Point of care testing • Prescription refills • Splints and assistive devices • IV lock • Medication (PO) • Simple wound care • Phone calls to the provider
10/30/2018 85Instructor/ Amparo Sanchez.
• Most patients in categories three, four, and five can wait in the waiting room.
• Patients who do not need to be seen in the ED but can be triaged to Urgent Care (UC) or Fast Track (FT).
10/30/2018 86Instructor/ Amparo Sanchez.
• Four and five could be seen in UC or FT if the facility has these resources available.
• If a facility does not have an UC or FT, all patients must be medically screened prior to sending them away from the area.
10/30/2018 87Instructor/ Amparo Sanchez.
10/30/2018 Instructor/ Amparo Sanchez. 88
• They must be monitored based on your facility’s protocols.
10/30/2018 89Instructor/ Amparo Sanchez.
Age Group Respirations Heart Rate Systolic Blood
Newborn 30-50 120-160 50-70
Infant (1-12 mo) 20-30 80-140 70-100
Toddler (1-3 y) 20-30 80-130 80-110
Preschooler (3-5 y) 20-30 80-120 80-110
School Age (6-12y) 18-25 70-110 85-120
Adolescent (13y +) 12-20 55-110 100-120
Adult 12-22 60-100 100- 140
10/30/2018 90Instructor/ Amparo Sanchez.
DISASTRE PLANNING/ROLE OF NURSE
A serious disruption of the functioning of a community that causes widespread human, material, economic, or environmental losses that exceed the ability of the affected community or society to cope with using its own resources.
INTERNAL DISASTERS • Are event in the
health care facility that threaten to disrupt the care environment
• Structural fire loss of power
• Personnel related(strike, high absenteism).
May be man –made or natural Man- made disasters
Transportation-related incidents, including, car, train plane, and subway crashes
Terrorist attacks Bombs, including suicide bombs and dirty bombs
Industrial accidents Chemical spills or toxic gas
leaks. Structural fire.
• Extreme weather conditions including blizzards, ice storms, hurricanes, tornadoes, and floods.
• Ecological disasters , including earthquakes, landslides ,tsunamis, volcanoes, and forest fire.
• Microbial disasters such as epidemics and pandemics.
• A situation can arise when and external disasters, such as a casualties and prevents health care providers from getting to the facility, perhaps due to the traffic or road conditions.
• Interagency cooperation within the community is essential in a disaster and requires.
• Coordination between community emergency system and health care facilities
• Developing a local emergency communication plan and/or network
• Identification of potential emergency public shelters.
ROLE OF THE NURSE • In the care facility . • Join Commission on
accreditation of Healthcare Organizations (JCAHO)mandates specific standards for hospital preparedness
• Disasters plans • Disasters drills
IN THE COMMUNITY • Education provided
to families about disasters planning.
1. What to do in an evacuation
2. Plan for family Pets
3. Where to meet in case of an emergency.
A FAMILY DISASTRERS KIT
Kit- Should include:
1. Flashlight with extra batteries
2. A battery- powered radio. 3. Nonperishable food that
requires no cooking(along with a nonelectric can opener)
4. One gallon of water per person.
5. Basic first-aid supplies
DISASTERS RELIEF ORGANIZATIONS • FEMA Federal
Emergency Management Agency.
• FEMA . • Is part of the U.S.
Department of Homeland Security.
• Manages federal response and recovery efforts.
AMERICAN RED CROSS
• Not a government agency, but authorized by the government to provide disaster relief.
• The American Red Cross provide:
Shelter and food to address basic human needs
Health and mental services.
Food to emergency and relief workers.
Blood and blood products to disaster victims.
HAZMAT • HAZMAT .Hazardous
Material Response Team.
Hazardous material may be radioactive flammable , explosive , toxic , corrosive, biohazardous, or may have other characteristics that make them hazardous in specific circumstances.
In a toxic exposure disaster, HAZMAT will coordinate the decontamination effort.
ROLE OF THE CHARGE NURSE DURING A DISASTER
• Preparation of a discharge list that feature clientes who can safety and quickly be discharged .
• Personal sent to the command center , if requerid.
• Off- duty personal called in , if requested.
• Desastre victimas are prepared for admissión.
• Reduce the intensity of and individual’s emotional reaction.
• Assists individuals in recovering from the crisis.
• Helps to prevent serious long-term problems from developing
10/30/2018 Instructor/ Amparo Sanchez. 106
• Cat scratch disease is a subacute, usually self-limited bacterial disease characterized by malaise, granulomatous lymphadenitis and variable patterns of fever. Symptoms of cat scratch fever include inflammation at the wound site but often rashes, inflammation and swellings at other places on the body because the germ is spread through the lymphatic system.
• It is often preceded by a cat scratch, lick or bite that produces a red papular lesion.
• Involvement of a regional lymph node follows, usually within 2 weeks.
• FIRST AID: Transmission of the germ into the lymphatic system or blood stream is greatly reduced if quickly and aggressively wash the bite wound or scratch with soap and water and a antiseptic.
10/30/2018 Instructor/ Amparo Sanchez. 108
10/30/2018 RN Amparo Sanchez Instructor 109
Rabies • Lyssavirus
• Affects Nervous System
– Saliva containing virus transmitted after a bite or scratch from an infected animal.
– Transmission person-to-person possible
– Hawaii only area in US that is rabies free.
– In US, wildlife rabies common in: skunks, raccoons, bats, foxes, dogs, wolves, jackals, mongoose, and coyotes
– Progresses to weakness/paralysis, spasm of swallowing muscles (results in hydrophobia), delirium and convulsions.
– Death usually from respiratory failure.
• The early symptoms of rabies are very generalized and include weakness, fever, and headaches. the suspicion of rabies as they are very similar to the common flu or other viral syndromes.
10/30/2018 Instructor/ Amparo Sanchez. 110
• The disease can then take two forms:
• With paralytic rabies (approximately 20% of cases), the patient’s muscles slowly get paralyzed (usually starting at the site of the bite), is the less common form and ends in coma and death.
• With furious rabies (about 80% of cases), the patient exhibits the classic symptoms of rabies, such as
10/30/2018 Instructor/ Amparo Sanchez. 111
10/30/2018 RN Amparo Sanchez Instructor 112
Rabies Treatment & Preventive Care:
• Allow free bleeding and drainage
– Vigorously clean wound with soap and water
– Human Rabies immune globulin.
– Tetanus prophylaxis.
– Immunization with Human Diploid Cell Rabies vaccine or Rabies vaccine for higher risk persons.
• Risk: Animal care workers, animal shelter personnel
10/30/2018 Instructor/ Amparo Sanchez. 113
• The main sources of radiation exposure in a healthcare facility are x-rays and radionuclides used in diagnostic tests and therapy. Areas where radiation is used are marked with the international tri-foil symbol (http://www.epa.gov/radiati on/students/symbols.html
10/30/2018 114INSTRUCTOR : AMPARO SANCHEZ
Radiation Safety • However, portable x-ray
machines may be found in unmarked areas.
• During exposure to radiation, you should limit your time as much as possible,
• Move at lease six to ten feet from the source, and wear leaded shields.
• If your job requires routine exposure, you should wear a monitoring device to measure your exposure.
10/30/2018 115INSTRUCTOR : AMPARO SANCHEZ
Radiation Safety • When working with
radioactive material, wash your hands well and dispose of trash in the appropriate manner.
• Do not eat, drink, smoke, or apply products to your skin in an area where radioactive material is being used
10/30/2018 116INSTRUCTOR : AMPARO SANCHEZ
RADIUM AND SAFETY
Particular cases of patients with inserted needle of radium for radiotherapy of cervical or prostatic cancer:
10/30/2018 RN Amparo Sanchez Instructor 118
RADIUM AND SAFETY • Nurse must wear x-ray badge and
check frequently for exposure to radiation.
• Limit time of visit with the client (maximum 1 hour every eight hours)
• Pregnant women or children not allowed to visit.
• Speak to client from the side
• Prepare meal outside the room.
• Place a sign outside the door to identify radiation risk
10/30/2018 RN Amparo Sanchez Instructor 119
RADIUM AND SAFETY • Client should have
bracelet identifying radiation risk.
• Client should be instructed to flush the toilet twice
• If radium is dislodged it has to be picked up with forceps
• Client has to be in private room
10/30/2018 RN Amparo Sanchez Instructor 120
BIOTERRORISM AND SAFETY
• There are 3 forms of absorption; transcutaneous, inhaled or gastrointestinal.
10/30/2018 RN Amparo Sanchez Instructor 121
BIOTERRORISM AND SAFETY
• Signs & symptoms:
• Bacillus will enter and open wound, cut or abrasion
• A raised itchy bump will appear
• -1-2 days later a black or necrotic painless ulcer, about 1-3 cm will appear.
10/30/2018 RN Amparo Sanchez Instructor 122
BIOTERRORISM AND SAFETY
Inhalation of anthrax:
• Signs of common cold, sore throat, mild fever, muscle aches and malaise. No RUNNY NOSE.
• Symptoms will progress for several days and may develop into breathing problems and shock
• High probability of fatality.
10/30/2018 RN Amparo Sanchez Instructor 123
BIOTERRORISM AND SAFETY
• Follows consumption of infected contaminated meal, followed by nausea vomiting, loss of appetite, vomiting of blood.
• Death will occur in 25-60% of all types of anthrax symptoms will usually occur 7 days after infection.
10/30/2018 RN Amparo Sanchez Instructor 124
BIOTERRORISM AND SAFETY
Anthrax.Treatment: • Broad spectrum
antibiotic such as ciprofloxacin, doxycycline, or penicillin.
10/30/2018 RN Amparo Sanchez Instructor 125
BIOTERRORISM AND SAFETY
Botulism: Botulism is a rare but serious disease that leaves few survivors. There are three main types of Botulism: infant botulism, botulinum spores are mainly found in the environment and bee honey,foodborne botulism, and wound botulism. • Causative Agent: Clostridium
botulinium. This agent can be used as a biological weapon.
• This disease is neuroparalytic, means it paralyzes the muscles.
10/30/2018 RN Amparo Sanchez Instructor 126
BIOTERRORISM AND SAFETY
Symptoms will be occur between 6 hours and up to 2 weeks after exposure the average time it will take to see symptoms is 12-36 hours.
• Client will have difficulty swallowing, dry mouth.
• Will have double vision
• Mental state is intact
• No fever.
• Descending flaccid paralysis
• This is diagnosed clinically and confirmed by culturing for the presence of the toxin in serum, stool or food.
10/30/2018 RN Amparo Sanchez Instructor 127
BIOTERRORISM AND SAFETY
• Antitoxin reduces the severity of the symptoms if administered early.
• Can only be received from CDC
• Contaminated surfaces should be cleaned with bleach.
10/30/2018 RN Amparo Sanchez Instructor 128
BIOTERRORISM AND SAFETY Ricin :
• Ricin is an extremely toxic plant protein derived from the seeds of the castor bean plant (Ricinus communis). May cause severe allergic reactions. Exposure:Exposure to even a small amount of ricin may be fatal.
• Ricin can be exposed to Ricin via inhalation, through consumption in water or food.
10/30/2018 RN Amparo Sanchez Instructor 129
BIOTERRORISM AND SAFETY
• There is no antidote for Ricin.
• Therefore, the only safety precautions available is to try no be exposed to it.
• Remove your clothing.
• Wash yourself with soap and water
• Dispose of clothes in a plastic bag and avoid touching contaminated areas
• Wear rubber gloves.
10/30/2018 RN Amparo Sanchez Instructor 130
BIOTERRORISM AND SAFETY
• Major symptoms will occur as early as 8 hours after exposure
• Difficulty breathing, nausea, tightness in the chest
• Pulmonary edema
• Low blood pressure, respiratory failure
10/30/2018 RN Amparo Sanchez Instructor 131
Report what To Whom.
Animal bites. Law enforcement /animal control.
Abuse of elderly. Adult protective services.
Child Abuse. Child protective services.
Communicable diseases. States specific (most states are reportable to the health department)
10/30/2018 132RN AMPARO SANCHEZ INSTRUCTOR.
Torch syndrome refers to infections of the fetus or newborn.
• The syndrome is caused by one of the following:
• T (Toxoplasmosis)
• O (Other viruses, other infections ex. syphilis)
• R (Rubella)
• C (Cytomegalovirus)
• H (Herpes)
What can drug name endings tell you?
If they end in this They belong go this.
caine Local anesthetics.
done Opiod analgesics.
pril ACE inhibitors.
10/30/2018 134RN AMPARO SANCHEZ INSTRUCTOR.
10/30/2018 135Instructor/ Amparo Sanchez.
1 Of the four clients listed below, which responsibility should the nurse direct the technician to carry out first? A) 89 year old with COPD resting quietly on 2 liters of o2 needs morning vitals with 02 sat B) 77 year old with gastrointestinal bleeding needs bedside commode emptied. C) 55 year old diabetic with fasting blood sugar of 75, at 80% of breakfast and needs morning snack D) 49 year old with rheumatoid arthritis needs splints reapplied to both hands
10/30/2018 136Instructor/ Amparo Sanchez.
2 The nurse just received report on the following clients. Who should the nurse see first? A) 35 year old with suspected acute tubular necrosis, urine output totaled 25cc’s for the last two hours. B) 49 year old with cancer of the breast, 2 days post mastectomy, reported to be having difficulty coping with the diagnosis C) 54 year old with TB in respiratory isolation, requesting pain medication D) 36 year old with chest tube insertion after a spontaneous pneumothorax, respirations 16
10/30/2018 Instructor/ Amparo Sanchez. 137
3 After completing assessment rounds, which finding would the nurse report to the physician immediately?
A) client who has not had a bowel movement in 4 days abdomen is firm
B) client who had a pulse of 89 and regular now has pulse of 100 and irregular.
C) client who is very depressed and has eaten 10% of meals for the last 2 days
D) client who has developed a rash around the neck and face who has been on iv penicillin for 2 days
10/30/2018 Instructor/ Amparo Sanchez. 138
After receiving report on four clients at 7am, what should the nurse complete first?
A) Call physician to report antiemetic for client who has been vomiting
B) Notify family of a clients transfer to ICU for chest pain
C) Call a potassium level of 5.9 to the attention of the physician.
D) Begin routine assessment rounds, starting with the sickest client
10/30/2018 Instructor/ Amparo Sanchez. 139
5 A 42 year old client has a history of coronary heart disease and is brought into the ER complaining of chest pain. What initial action should be taken by the nurse?
A) Give the client ntg gr 1/150 sl now
B) Call the cardiologist about the admission
C) Place the client in a supine position after loosening the shirt
D) Check blood pressure and note the location and degree of chest pain.
10/30/2018 Instructor/ Amparo Sanchez. 140
6 As a nurse working the ER, which client needs the most immediate attention?
A) A 3 yr old with a barking cough, oxygen sat of 93 in room air, and occasional inspiratory stridor B) A 10 month old with a tympanic temperature of 102, green nasal drainage, and pulling at the ears C) An 8 month old with a harsh paroxysmal cough, audible expiratory wheeze and mild retractions D) A 3 year old with complaints of a sore throat, tongue slightly protruding out his mouth, and drooling.
10/30/2018 Instructor/ Amparo Sanchez. 141
7 The nurse is assigning tasks to the UAP. Which is an appropriate delegation to the UAP? Select all that apply. 1. Check the area around an incisional wound for redness 2. Help a client with an upper limb cast to eat. 3. Assist a patient recovering from a hysterectomy to walk to the bathroom. 4. Explain to a client being discharged how to empty and clean the colostomy 5. Transport a client with a suspected fractured tibia to the x-ray department.
10/30/2018 Instructor/ Amparo Sanchez. 142
Triage.First questions. 1. B) 77 year old with gastrointestinal bleeding needs bedside commode
2. A) 35 year old with suspected acute tubular necrosis, urine output totaled 25cc’s for the last two hours.
3. B) client who had a pulse of 89 and regular now has pulse of 100 and irregular.
4. C) Call a potassium level of 5.9 to the attention of the physician.
5. D) Check blood pressure and note the location and degree of chest pain.
6. D) A 3 year old with complaints of a sore throat, tongue slightly protruding out his mouth, and drooling.
7. 2. Help a client with an upper limb cast to eat. 3. Assist a patient recovering from a hysterectomy to walk to the bathroom.
5. Transport a client with a suspected fractured tibia to the x-ray department.
10/30/2018 Instructor/ Amparo Sanchez. 143
10/30/2018 144Instructor/ Amparo Sanchez.
Four aspects of the triage process include:
a. An across the room assessment, a history, a physical assessment and the screen for abuse and neglect.
b. Vital signs, allergies, history, and across the room assessment.
c. A general assessment, a history, a physical assessment and the disposition decision.
d. None of the above
10/30/2018 145Instructor/ Amparo Sanchez.
• When dealing with pediatric patients you do not need to worry about psychosocial aspects because kids cannot express themselves and have no real feelings or emotions.
• a. True
• b. False
• C. Is not necessary worry
• D.Kids have subjective feeling
10/30/2018 146Instructor/ Amparo Sanchez.
• ESI level 1 is the lowest priority.
• a. True
• b. False
10/30/2018 147Instructor/ Amparo Sanchez.
When a pediatric patient is in shock:
a. Their blood pressure will rise first.
b. The heart rate will rise first.
c. Both their blood pressure and heart rate will rise together.
d.None of the above
10/30/2018 148Instructor/ Amparo Sanchez.
Benefits of ESI triage include:
• a. Quick sorting.
• b. Discrimination of patients who do not need to be seen in the ED.
• c. Determination of thresholds for decision.
• d. All of the above
10/30/2018 149Instructor/ Amparo Sanchez.
While assessing and treating kids, you should use the same approach with every kid.
• a. True
• b. False
10/30/2018 150Instructor/ Amparo Sanchez.
When obtaining a history you should assess:
• a. Allergies
• b. Menstrual history
• c. Onset of symptoms
• d. All of the above
10/30/2018 151Instructor/ Amparo Sanchez.
The ABCDs of triage include:
• a. Allergies, bleeding, cancer history, and documentation.
• b. Age, bleeding, circulation, and documentation.
• c. Airway, breathing, circulation, and disability.
• d. Airway, bleeding, circulation and diagnosis.
10/30/2018 152Instructor/ Amparo Sanchez.
• A patient needing artificial ventilation would be classified as an ESI level:
• a. 1
• b. 2
• c. 3
• d. 4
• e. 5
10/30/2018 153Instructor/ Amparo Sanchez.
When assessing a child less than one month old, you begin your assessment with the:
• a. Head
• b. Fontanels
• c. Chest and abdomen
• d. None of the above
10/30/2018 154Instructor/ Amparo Sanchez.
It is not important to assess the blood pressure when triaging a patient. The heart rate and rhythm is the only vital sign to consider.
• A. True
• B. False
10/30/2018 155Instructor/ Amparo Sanchez.
The normal heart rate of a 16 year old is usually:
• a. 55-110
• b. 90-140
• c. 75-100
• d. 80-110
10/30/2018 156Instructor/ Amparo Sanchez.
• The first step in the decision process is:
• a. Obtain the chief complaint.
• b. Observe the patient and do a visual survey.
• c. Perform a focused assessment.
• d. Determine acuity category.
10/30/2018 157Instructor/ Amparo Sanchez.
• The only treatment necessary in triage is BLS.
• a. True
• b. False
10/30/2018 158Instructor/ Amparo Sanchez.
• The screening for abuse and neglect does not need to be completed in triage. The nurse assessing the patient after triage should do this.
• a. True
• b. False
10/30/2018 159Instructor/ Amparo Sanchez.
A 32year-old male arrives with a jar containing a rattlesnake and reports he was bitten by the snake approximately 30 minutes ago. This patient would be classified as an ESI level:
• a. 1
• b. 2
• c. 3
• d. 4
• e. 5
10/30/2018 160Instructor/ Amparo Sanchez.
When assessing respirations of the child you should assess:
• a. Quality
• b. Rate
• c. Effort
• d. All of the above
10/30/2018 161Instructor/ Amparo Sanchez.
A CBC, BMP, EKG, and a splint would be counted as how many resources?
• a. 1
• b. 2
• c. 3
• d. 4
10/30/2018 162Instructor/ Amparo Sanchez.
Which of the following would not be considered a resource:
• a. Phone call to the provider
• b. EKG
• c. Consult
• d. Tetanus shot
10/30/2018 163Instructor/ Amparo Sanchez.
10/30/2018 164Instructor/ Amparo Sanchez.
• After receiving a report from the night nurse, which of the following clients should the nurse see first?
1.- A 31 year-old woman refusing sucralfate (carafate) before breakfast
2. A 40 year-old man with left-side weakness asking for assistance to the commode
3. A 52 year-old woman complaining of chills who is scheduled for a cholecystectomy
4. A 65 year-old man with a NG tube who had a bowel resection yesterday
10/30/2018 Instructor/ Amparo Sanchez. 165
• An 11 year old male is playing with an archery set and is accidently shot in the left side of the chest. His neighbor, that is a nurse, notes the child is about to remove the arrow. The appropriate action at this time is:
a. Assist the child in removal of the arrow b. Prevent the removal of the arrow, and secure with a
clean towel to prevent dislodgement c. Reassure the mother that there is no serious damage
since he is able to move d. The priority is to call 911, do not stop this action to
prevent removal of arrow
10/30/2018 Instructor/ Amparo Sanchez. 166
• The graduate nurse working on a pediatric surgery unit presents the preceptor with the assignment for the unlicensed assistive personnel (UAP) and the licensed practical nurse(LPN). Which of the following tasks would the preceptor question?
a. UAP assigned to walk with a child admitted with diagnosis of croup
b. LPN assigned to teach a class to adolescence on proper nutrition
c. UAP assigned to feed a 10 month old child
d. LPN assigned to administer a prescribed PO antibiotic
10/30/2018 Instructor/ Amparo Sanchez. 167
• The nurse preparing to administer digoxin (Lanoxin) to a 67-year old man with Congestive Heart Failure, which of the following clinical manifestations would the nurse associate with digoxin toxicity?
• 1. Cyanosis
• 2. Visual disturbances
• 3. Hypertension
• 4. Inconsolability
• 5. Weakness
• 6. Headache
• a. 2, 3
• b. 4, 6
• c. 1, 2, 4
• d. 2, 5, 6
10/30/2018 168RN Instructor Amparo Sanchez
A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate?
• A: Gluteus maximus
• B: Gluteus minimus
• C: Vastus lateralis
• D: Vastus medialis
10/30/2018 169RN Instructor Amparo Sanchez
• A home health nurse is caring for a client with a pressure sore that is red with serous drainage and two inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound should be which of these?
• 1. A transparent film dressing
• 2. A wet dressing with debridement granules
• 3. A wet to dry with hydrogen peroxide
• 4. A moist saline dressing
10/30/2018 Instructor/ Amparo Sanchez. 170
• When a primary survey of a trauma client is conducted, what is considered one of the priority actions that must be performed?
1. Obtaining a complete set of vital sign measurements.
2. Palpating and auscultating the abdomen.
3. Performing a brief neurologic assessment.
4. Checking the pulse oximetry reading
• You are charge nurse in an emergency department ED and must assign two staff members to cover the triage area .Which team is the most appropriate for this assignment?
1. And advanced practice nurse and experienced LPN LVN
2. An experienced LPN /LVN and an inexperienced RN
3. An experienced RN and an inexperienced RN.
4. An experienced RN and a nursing assistant
• You respond to a call for help from the ED waiting room. An elderly client is lying on the floor. List the order in which you must carry out the fallowing actions.
1. Perform the chin lift or jaw thrust maneuver
2. Establish unresponsiveness
3. Initiate cardiopulmonary resuscitation(CPR)
4. Call for help and activate the code team
5. Instruct a nursing assistant to get the crash cart.
1. 4.An experienced traveling nurse has been assigned to work in the ED ; however, this is the first’s week on the job . Which area of the ED is the most appropriate assignment for this nurse?
3-Ambulatory or fast-track clinic.
4-Pediatric medicine team
• You are assigned to telephone triage . A client who was just stung by a common honeybee calls for advice . The client report pain and localized swelling but has no respiratory distress or other systemic sign of anaphylaxis . What is the first action that you should direct the caller to perform?
1-Call 911 2-Remove the stinger by scraping 3-Apply a cool compress 4-Take an oral antihistamine
QUESTION # 33
An anxious 24 years old college student complaint of tingles sensation , palpitation , and chest tightness . Deep , rapid breathing and carpal spasms are noted . What priority nursing action should you take?
1-Notify to the physician immediately
2-Administer supplemental oxygen
3-Have the student breathe into the paper bag.
4-Obtain an order for an anxiolytic medication
QUESTION # 34
• A teenager arrives in the triage area alert and ambulatory, but his clothes are covered with blood. He and his friends are yelling, “we were are goofing around and he got poked in the abdomen with a stick ”. Which comment should be given first consideration?
1-”There was a lot of blood and we used three bandages”
2-He pulled the stick out ,just now, because it was. hurting him
3-The stick was really dirty and covered with mud
4-he’s a diabetic, so he needs attention right away’’
• In the care of a client who has experienced sexual assault , which task is most appropriate for an LPN/LVN to perform?
• 1-Asses immediate emotional state and physical injuries
• 2-Collect hair samples, saliva specimen and scrapings beneath fingernails
• 3-Provide emotional support and supportive communication.
• 4-Ensure that the ‘’chain of custody’’ of evidence is maintained
• You are caring for a client with multiple injuries sustained during a head-on car collision .Which assessment finding take priority
• 1-A deviated trachea.
• 2-Unequal pupils
• 3-Ecchymosis in the flank area
• 4-Irregular apical pulse
• The nurse manager decides to from a committee to address the issue violence against ED personnel Which combination of employees would be best suited to fulfill this assignment?
• 1-ED physicians and charge nurses
• 2-Experienced RNs and experienced paramedics
• 3-RNs LPNs /LVNs and nursing assistants
• 4-At east one representative from each group of ED personnel.
10/30/2018 Instructor/ Amparo Sanchez. 181
1: True : All women of childbearing age are considered pregnant until proven otherwise. 2: A general assessment, a history, a physical assessment and the disposition decision. Four aspects of
the triage process include. 3:False: When dealing with pediatric patients you do not need to worry about psychosocial aspects
because kids cannot express themselves and have no real feelings or emotions. 4: False : ESI level 1 is the lowest priority. 5: The heart rate will rise first. When a pediatric patient is in shock: 6: All of the above :Benefits of ESI triage include 7: False :While assessing and treating kids, you should use the same approach with every kid. 8: All of the above :When obtaining a history you should assess. 9: Airway, breathing, circulation, and disability :The ABCDs of triage include. 10: 1 :A patient needing artificial ventilation would be classified as an ESI level 11: Chest and abdomen :When assessing a child less than one month old, you begin your assessment
with the: 12: False :It is not important to assess the blood pressure when triaging a patient. The heart rate and
rhythm is the only vital sign to consider. 13: 55-110 :The normal heart rate of a 16 year old is usually. 14: Observe the patient and do a visual survey :The first step in the decision process is. 15: False :The only treatment necessary in triage is BLS.
10/30/2018 182Instructor/ Amparo Sanchez.
• 15: False: The only treatment necessary in triage is BLS. • 16: False: The screening for abuse and neglect does not need to be
completed in triage. The nurse assessing the patient after triage should do this.
• 17: 2: A 32year-old male arrives with a jar containing a rattlesnake and reports he was bitten by the snake approximately 30 minutes ago. This patient would be classified as an ESI level:
• 18: All of the above: When assessing respirations of the child you should assess:
• 19: 2: A CBC, BMP, EKG, and a splint would be counted as how many resources?
• 20: Phone call to the provider :Which of the following would not be considered a resource.
10/30/2018 183Instructor/ Amparo Sanchez.
Answers. 21/ 1: CORRECT | Assessment: Outcome priority, must evaluate competency of the UAP. Nurse is a accountable for UAPs actions
during delegation process. 22.3 Remember physiology coming first. 23/ Correct: B. A foreign object should never be removed for the client, unless in a controlled secure environment. It is a priority
to obtain emergency medical assistance from 911, but the child must be prevented from removing the arrow to avoid exsanguination.
24/.Correct: B It is within an unlicensed assistive personnel job description to assist clients with walking and feeding themselves. A licensed practical nurse can administer medications; however teaching is not within the scope of practice of a LPN. It is the responsibility of the registered nurse to provide client education.
25/ Correct: D. The clinical manifestations associated with digoxin toxicity include, visual disturbances, weakness, headache, apathy and potentially psychosis.
26. (C) Vastus lateralis is the most appropriate location. 27 4/The correct answer is: A moist saline dressing 28/Ans:3 a brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey
. 29/ 3 triage requires at least one experienced RN Pairing and experience RN with and inexperienced RN provide opportunities
for mentoring. Advanced practice nurse are qualified to perform triage. 30/2,4,1,3,5 31/3 The fast track clinic deal with the client in relatively stable condition . The triage trauma and pediatric medicine area should
be staffed with experienced nurse who knows the hospital routine and policies and can rapidly locate equipment. 32/ 2 The stinger will continue to release venom into the skin , so prompt removal of the stinger is advised. Cool compress of
antihistamine can follow . The caller should be further advised about symptoms that require 911 assistance . 33/ 3.The client is hyperventilating secondary to anxiety and breathing into the paper bag will allow rebreathing of carbon
dioxide. Also encouraging slow breathing will help 34/ 2 An impaled object may be providing a taponade effect , and removal can precipitate sudden hemodynamic
decompensation. Additional history , including a more definitive description of the blood loss, depth of penetration , and medical history , should be obtained .
35/3 An LPN/LVN IS able to listen and provide emotional support for clients. The other task are the responsibility of the RN 36/ 1 A deviated trachea is a symptom of tension pneumothorax , which will result in respiratory arrest if not corrected .All of the
other symptoms need to be addressed , but are of lower priority 37/ 4 At lest one representative from each group should be included, because all employees are potential targets for violence in
PATIENT PRESENTS WITH TRIAGE CATEGORY
•Open fracture •Extremity injury with severe deformity or neurovascular compromise (decreasing pulse, sensation or movement) •Laceration with uncontrolled bleeding. •Neck pain secondary to trauma<48hour or associated with stiff neck. •Major burns-burns with>10% TBS all burns of the face ,hands, genitalia and feel any burns in a child under age 1 year •Pain beneath cast with neurovascular compromise (compartment syndrome)
Animal bite (injury not severe.
• Active vomiting or diarrhea.
• Temperature 101 F for infants (over 6 months old) children and adults.
• Temperature under 101F in well-appearing>6 months old. Severe rectal pain
• UTI with severe discomfort
• Intermittent rectal bleeding (>spotting and <an active bleed ,)including bleeding hemorrhoids.
Temperature under 101 F in well –appearing child>6 month old.
• Rash with normal vital signs
URGENT TRIAGE .AMPARO
• Pain beneath existing cast without neurovascular compromise
• Laceration with controlled bleeding. • Closed fracture suspected without deformity or
neurovascular compromise. • Back pain secondary trauma in last 72 hours. • Minor burns-other than major burns. • Patients who are not at risk for immediate morbidity or
mortality but who require priority care . • Patients shall be escorted to the appropriate treatment
room where a primary nurse will take over their care.
NO –URGENT TRIAGE AMPARO • Sprain/bruises without obvious deformity. • Extremity pain without neurovascular compromise. • Chronic back pain. • Minor injury greater than 72 hours old. • Wound check, suture removal. • Respiratory symptoms with no acute distress • Non-productive cough • Cold symptoms(sore throat , runny nose, etc • Patients for whom delayed treatment will not lead to
significant increased morbidity or mortality. • Patient shall be interviewed and brought to ED treatment
area when available and a primary nurse can accept them . • The patient can be seated in the waiting area and advised
as to the projected waiting time.