Maria Leonie Dela Cruz

BSN 460 - Block AAA

1. Levi is a 25-year old male. He is able to follow commands but has trouble hearing. His
capillary refill is <2 seconds, radial pulse is nonexistent, can’t move due to a compound
left femur fracture, respirations are >30cpm and he is coughing. What color tag is he and
why?
a. Answer: RED
b. Green is assigned to all patients who can walk, thus named “walking wounded.”
Levi on the other hand can’t move due to his fracture. Although he has a capillary
refill of < 2 seconds, he has respirations over 30 cpm. According to the START
algorithm, patients with respirations of over 30 cpm and non-existent radial pulse
are placed under the immediate/red tag, hence Levi’s color tag is red.

2. Mikasa is a 21-year old female. She can follow commands but is scared. Her capillary
refill is <2 seconds, has a radial pulse, respirations are <30 cpm with shortness of
breath. She has a sudden onset of chest pain. What color tag is she and why?
a. Answer: YELLOW
b. Mikasa has respirations under 30 cpm, present radial pulse, capillary refill under
2 seconds, and being able to follow simple commands keeps her away from the
red tag, and being under the yellow tag instead. This is because even though she
has shortness of breath and chest pain (which are also probably caused by her
anxiety), there are no signs that place her under the red tag according to the
START algorithm.

3. Annie is a 35-year old female. She is alert, glossy sheen to exposed skin, capillary refill
is <2 seconds, respiration rate 16 cpm, a cutright forearm, minimal bleeding, some white
glowing powder seen on casualty. What color tag is she and why?
a. Answer: GREEN
b. Annie is alert, has a capillary refill time of < 2 seconds, respirations of 16 cpm
(<30 cpm), and only has a cut in her right forearm with minimal bleeding. She
doesn’t seem to have any problems walking around. All this information places
her under the green tag based on the START algorithm. But this does not mean
we get to ignore the glowing white powder seen on casualty as this could be
some sort of drug or radioactive material, which means the patient must be
monitored for any sudden changes.

4. Eren, a 51 year old, installing a ceiling fan assisted by his friend. He was thrown back
and his friend immediately switched off the power and called an ambulance. B2 had a
brief period of loss of consciousness, alert when the ambulance arrived, in and out of
consciousness during the trip to the ED. BP= 150/90 mmHg, PR=88bpm, RR 20cpm,
O2sat = 91%
a. Answer: RED, Level 2
b. Eren was electrocuted while trying to install a ceiling fan. Although he was alert
when the ambulance arrived, he has been going in and out of consciousness on
the trip to the ED. He also has high blood pressure. He can’t follow simple
commands since he has been going in and out of consciousness since arriving at
 the ED, which is probably a sign of his deteriorating condition. And although he
has normal respirations, his oxygen saturation is only 91%, which is very low.
This puts him under the red tag. One major sign that he is placed under ESI level
2 is because he doesn’t need immediate intervention but we can clearly see that
his level of consciousness is getting worse. Although he has pretty normal vitals
aside from the high blood pressure, he used to be alert when the ambulance
arrived and now he seems to be going in and out of consciousness on the trip to
the ED. Not to mention his oxygen saturation is below 92%. According to the ESI
Triage Algorithm, he belongs in the 2nd level.

5. Armin, a 7-year old, an Ilocano speaking child, is brought to the ED in her father’s car.
You are called to assist her to get out of the car. The father tells you she is ‘very sick’
and you noted that she is able to transfer to a wheelchair with minimal assistance but
cringes and cries out when her hips are moved. According to her father, she fell from her
upper double deck bed in their house. HR= 110bpm, RR= 40cpm, O2 sat= 91%
a. Answer: RED, Level 2
b. Armin cringes and cries out when her hips are moved, which might be a sign of a
hip injury. Her respirations are over 40 cpm (>30 cpm), which according to the
START algorithm, is under the red tag. She also has very low oxygen saturation
with only 91%, which means she is under respiratory distress. She falls under
ESI level 2 since she experiences severe pain when her hips are moved. And
according to the ESI Triage Algorithm, respirations >30 cpm and an oxygen
saturation <92% are signs that you should put the patient under the level 2 of the
ESI.