What is Triaging?

Triage is a French word meaning selection, classification. In the health field triage means to
classify the function of patients before they receive the provision of care they need. This
function is set to classify where a significant number of patients. That’s why the military health
was the first institution to introduce a triage system in the battlefields of the Great War. The
Civil Health, triage is performed in Disaster and accidents with multiple victims.

Triage refers to the evaluation and categorization of the sick or wounded when there are
insufficient resources for medical care of everyone at once. Historically, triage is believed to
have arisen from systems developed for categorization and transport of wounded soldiers on
the battlefield. Triage is used in a number of situations in modern medicine, including:

 In mass casualty situations, triage is used to decide who is most urgently in need of
transportation to a hospital for care (generally, those who have a chance of survival
but who would die without immediate treatment) and whose injuries are less severe
and must wait for medical care.

 Triage is also commonly used in crowded emergency rooms and walk-in clinics to
determine which patients should be seen and treated immediately.

 Triage may be used to prioritize the use of space or equipment, such as operating
rooms, in a crowded medical facility.

In a walk-in clinic or emergency department, an interview with a triage nurse is a common

first step to receiving care. He or she generally takes a brief medical history of the complaint
and measures vital signs (heart rate, respiratory rate, temperature, and blood pressure) in
order to identify seriously ill persons who must receive immediate care.

Responsibilities of an Emergency Nurse.

ER Nurses provide direct and individualized nursing care to patients based on the application of
scientific nursing principles. In addition to general nursing care, responsibilities of ER Nurses include
(but are not limited to):

Collects current symptoms, as well as a detailed patient history and then consults and coordinates
with health care team members to assess, plan, implement and evaluate patient care plans ƒ Performs
triage, while considering both physical and psychosocial elements

 Manages basic life support needs and stabilizes patients until the attending physician is
available, based upon nursing standards and protocol
 Initiates corrective action whenever information from monitoring equipment shows adverse
symptomatology ƒ Records patients’ current vital signs
 Works directly under physicians, assisting them during exams, diagnostic testing and
treatments
  Prepares and administers (orally, subcutaneously, through an IV) and records prescribed
medications. Reports adverse reactions to medications or treatments in accordance with the
policy regarding the administration of medications by a licensed registered nurse
 Provides IV therapy
 Cleans and bandages wounds
 Provides basic, bedside care
 Maintains proper supplies and appropriate medical equipment to care for patients
 Reports any suspected abuse to the appropriate agencies
 Initiates patient education plan, as prescribed by physician. Teaches patients and significant
others how to manage their illness/injury, by explaining: post-treatment home care needs,
diet/nutrition/exercise programs, self-administration of medication and rehabilitation, as
well as provides referrals to other healthcare professionals for follow-up treatment
 Displays professionalism while completing multiple urgent tasks in a timely manner
 Records all care information concisely, accurately and completely, in a timely manner, in the
appropriate format and on the appropriate forms General Healthcare Resources, Inc. is an
Equal Opportunity Employer
 Performs other position-related duties as assigned, depending on assignment setting

Emergency Drug
Name of Dosage/Rou Action/Classificati Indication/ Adverse Effects/ Nursing
the te on Contraindicatio Side Effects Responsibilities
Drug ns
Generic Adults: Action Indications: Adverse Effects: Blood is not a
Name: initially, 1 to Stimulates To treat shock Cv: anginal pain, substitute for
Dopamin 5 dopaminergic and and correct arrythmias, blood or fluid
e HCl. mcg/kg/minu alpha and beta hemodnamic bradycardia, volume deficit.
te by I.V. receptors of the imbalances, conduction If deficit occurs,
Brand infusion. sympathetic improve disturbances replace fluid
Name: Adjust dose nervous system. perfusion of vital ectopic deficit first
Intropin; to desired Action is dose- organs, to breasts,hypertensi before giving
Revimin hemodynami related; large doses increase cardiac on, hypotension, meds.
e c or renal can cause mainly output, and to palpitations,
response, alpha stimulation. correct tachycardia, During
increase by 1 hypotension. vasoconstriction, infusion,
to 4 Classification: widening of QRS frequently
mcg/kg/minu Inotropic, Contraindicatio complex. monitor ECG,
te at 10 to vasopressor ns: BP, cardiac
30-minute Contraindicated GI: vomiting. output, CVP,
intervals. in patient with pulmonary
uncorrected GU: azotemia artery wedge
tachyarrhythmias Respiratory: pressure, pulse
, asthma attacks, rate, urine
pheocromocyto dyspnea output, and
ma, or color and
ventricular Skin: temperature of
fibrillation. necrosis,piloerecti the limbs.
- Use cautiously on, tissue
in patients with sloughing with If diastolic
occlusive extravasation. pressure rises
 vascular disease, disproportionate
cold injuries, Other: ly, decrease
diabetic anaphylaxis. perfusion rate
endarteritis, and and watch out
arterial Side Effects: carefully for
embolism; in CNS: headache further signs of
pregnant GI: nausea vasoconstriction
woman; with a unless such
history of sulfite action is desired.
sensitivity; and
in those taking Observe for
MAO inhibitor. adverse reaction.

Check for urine

output. If urine
flow is decrease
without
hypotension,
notify physician.

After drug is
stopped, Tamper
dosage slowly to
evaluate
stability of
blood pressure.

Acidosis
decrease
effectiveness of
dopamine.

Standards and Protocols in the Emergency Room (DOH)

Emergency Room – Most important area for reception of mass casualties, triage and treatment. The
emergency room must have:

 Reception Area/Admission – The area should be available on short notice to receive multiple
casualties for registration and admission.
 Triage Area – The primary function of a triage area is rapid assessment of all incoming
casualties, the assignment of priorities for management, and distribution of patients to
various other patient care areas in the hospital. Without a triage area to manage the patient
flow, the major treatment area may become overloaded.
 Decontamination Area – Physically located before the entrance of the emergency room, the
decontamination area is provided with facilities for security and privacy of the patient,
bathing of the patient, disposal of contaminated clothing and other materials, contaminated
water disposal/drainage, and draping of decontaminated patients and decontamination
team. The decontamination team members should be provided with the appropriate personal
protective equipment. Decontamination is not routinely done to all patients. It is specifically
used only if there is a high index of suspicion for biological, chemical and radio nuclear
incidents.
Patient Care Stations – One suggested method of organizing patient care stations is the designation
of areas physically located in the Emergency Department for color -tagged patients (WHO and ADPC,
2006). Stations may be designated as:

Red – Immediate Care Area: red tag patients

Yellow – Urgent Care Area: yellow tag patients
Green – Delayed Care Area: green tag patients
The college of Health Sciences Education

In Partial Fulfilment of the Requirement in,

NCM/RLE code: 04170

Submitted by:

Marie Faye S. Emuy, SN, UM

Submitted to:

Prof. Mary Ann Guyot, RN, MN.

Date: August 19, 2019