EMERGENCY NURSING ED Triage Vs.

FIELD Triage
I.ISSUES IN EMERGENCY NURSING CARE  Routine Triage – directs all available
1. Documentation of consent and privacy resources to the patients who are most
Who can give consent? critically ill , regardless potential
I. Patient outcome.
II. SO/ next of kin
“what makes you worst, makes you first”
III. Physician
- principle of paternalism  Field Triage :used during a disaste: mass
* documentation: casualty
i. pt’s condition - scarce resources must be used to
ii. state that no SO is present benefit the most people possible.
iii. Treatment and time its given (Hospital triage during a disaster)
2. Limiting exposure to Health Risks
“ do the greatest good for the greatest number”
* exposed to bodily fluids, blood and Respi
- utilitarianism
Droplets
❖ Routine Triage
- standard precaution
Three Categories: 3 Level Triage (most basic and
3. Violence in the Emergency Department
widely used triage system)
- safety
1. Emergent (requires immediate action: 1-2hrs)
4. Providing Holistic Care
- highest priority
Stages of Crisis: - life threatening condition (compromised
1. Anxiety – initial goal: Reduce anxiety: ABC)
Therapeutic Communication 2. Urgent ( requires prompt action: 24-48 hrs)
2. Denial - serious health problem but not
3. Remorse & Guilt immediately life threatening

4. Anger 3. Non-urgent

5. Grief - episodic illness (cough, cold)

6. Reconciliation
II. PRINCIPLES OF EMERGENCY CARE
By definition, Emergency care is care that must be
rendered without delay . In an ED, several
patients with diverse health problems – some life-
threatening, some not – may present to the ED
simultaneously. One of the first principles of
Emergency care is _Triage_.
1. TRIAGE
- French word: “Trier”
Meaning: To sort
Triage is used to sort patients into groups
based on the severity (acquity) “how life
threatening” of their health problems and
the immediacy (does pt condition require
immediate tx) with which these problems
must be treated.
TRIAGE is an advanced skill. Emergency nurses
spend many hours learning to classify different
illnesses and injuries to ensure that patients most
in need of care do not needlessly wait.
The goal of all TRIAGE is rapid assessment and
rapud decision making preferably under 5 mins.
2. Assess and Intervene
A systematic approach to effectively establishing
and treating health priorities is the Primary
survey and Secondary survey
approach.
PRIMARY SURVEY
• Purpose: stabilize Life-threatening
conditions
• follow ABCDE method
A- airway (can oxygen enter the lungs?) - Use of accessory muscles and flaring
nostrils
B- breathing (can O2 in the lungs be absorbed to
- Increased anxiety, restlessness, confusion
the lungs?)
- Cyanosis and dec. LOC (late sign)
C- circulation (can O2 in the blood be distrusted
C- confusion
to the body?)
D- disorientation, dizziness,
D- disability: Neurologic disability: assess brain
delirium
function
L- lethargy
E- exposure: undress the patient (quickly and
gently) O- obtundation – dec response to
stimuli
- to be able to assess areas for wound and injuries
S- stuporous – drowsy; dozy
I. Airway
C- coma
• Airway Obstruction
Position: High Fowler’s
a. Partial obstruction - progressive
hypoxia and hypercarbia brain detects 1. Sitting
compensatory mechanism 2. Upright
3. Head of bed 90 deg.
1. Increased Respiratory Rate 4. High back rest
2. Inc Heart Rate
Management: OPEN AIRWAY
Cardiac and Respiratory Arrest
1. Partial obstruction – pt can breathe and cough
Death spontaneously
b. Complete obstruction – airway Management: encourage pt to cough forcibly
movement is absent
2. Complete Airway Obstruction
O2 deficit to the brain
Management: Reposition the pt’s head
Restlessness ( fall unconscious)
a. head tilt/ chin tilt
Permanent and irreversible brain damage
within 3-5 mins DEATH
Causes:
3 most common causes:
1. Anaphylactic reaction (laryngospasm)
2. Infection
3. Angioedema
Other causes
1. aspiration of foreign objects
2. trauma b. jaw thrust
3. inhalation of chemical burns - Assess pt for breathing by watching for chest
A. aspiration of foreign objects movement and listening and feeling for air
movementESTABLISHING AN AIRWAY
- Universal Distress Signal
(clutching of the neck)
- Cannot speak, breath, or cough
- Chocking, apprehensive appearance,
refusing to lie flat, inspiratory and
expiratory stridor, labored breathing
1. Oropharyngeal airway (OPA)
- circular tubelike plastic device
- inserted over the back of the tongue into
the lower posterior pharynx
- for pt: breathing spontaneously but
unconscious
- purpose: prevents the tongue from falling
back causing obstruction in airway; also
allows suctioning of secretions
II. BREATHING
- provide adequate ventilation
- Pt’s who have experienced trauma must
have the cervical spine protected and
chest injuries assessed first, immediately
after securing airway
1. Flail chest – 2/more ribs detached ribcage
2. Rib Fracture
3. Paradoxical Breathing – reverse

III. Circulation
- Any heart problem is a circulatory
problem
Shock – inadequate tissue perfusion leading to
2. vital organs failure
Nasopharyngeal airway (NPA)
Circulatory Organs:
- provides the same airway access but
inserted in the nares 1. Heart
- a nasopharyngeal airway should be tried if 2. Blood Vessels
a pt does not tolerate OP
3. Blood
✔ Quality & Safety Nursing Alert 3 classifications of Shock

In case of potential facial trauma or basal skull A. Hypovolemic shock - blood volume
Blood
fracture, the nasopharyngeal airway should not 1. Hemorrhage
be used because it could enter the brain cavity
2. Dehydration
instead of the pharynx.
3. Burns
B. Cardiogenic Shock – cardiac outpu
3. Endotracheal Intubation Heart
1. Congestive Heart Failure
• Purpose: establish and maintain the
airway in patients with respiratory 2. Cardiac Tamponade
insufficiency or hypoxia 3. Dysrhythmia
• Indications: Blood
C. Distributive
vessels Shock – massive vasodilation
- if pt is not adequately with OPA and NPA
1. Septic shock – infection
- bypass an upper airway obstruction
2. Anaphylactic shock – allergic
- prevent aspiration
3. Neurogenic/ Spiral shock – brain and
- permit connection to a rescu bag or mech vent spinal cord
- facilitate removal of tracheobronchial secretion
A. Hypovolemic shock B. fluid of choice for rapid IV rescusitation
Assessment: ISOTONIC
- cool moist skin: cold and clammy a. PNSS
- decreasing BP: decrease blood volume b. PLRS -
- increasing HR: Compensatory mechanism c. D5W
- delayed CRF: decrease perfussion
- decreasing urine volume: uliguria 3. Prevent Shock
1. decrease renal Perf – pt is maintained in the shock position
2. increase reabsorption a. modified Trendelenburg – supine body,
elevated LE
Triad of shock: HypoTachyTachy
b. Trendelenburg- inc ICP
Management:
The goals of the emergency management for ✔ Quality and Safe Nursing Alert
hemorrhage:
1. Stop/control bleeding The infusion rate is determined by severity of
blood loss the and the clinical evidence of
2. Maintain Adequate Circulating Blood Hypovolemic . Any blood replacement therapy
Volume should be given via Warm when possible, because
3. Prevent Shock administration of large amounts of blood that has
been refrigerated has a core cooling effect that
may lead to cardiac arrest and coagulopathy.
The goals of the emergency management:
1. Control the Bleeding - stopping the bleeding is IV. Disability
essential to the care and survival of patients in an
emergency or disaster situation - Determine neurologic disability
(neurologic brain function)
a. Rapid Physical Assessment – identify sites of
blleding a. GCS : Eye response – 4 pts
b. Apply PIE: Pressure, Immobilize, Elevate Verbal Response – 5 pts
a. elevate Motor Response – 6 pts
b. immobilize b. AVPU : Alert
c. pressure Verbal/Voice
d. tourniquet Pain
C. Last ResortL: Tourniquet Unresponsive
- location, time V. Exposure
2. Maintain adequate circulating blood volume - Undress the pt ___________ and
byv _____________ so that any wounds or
areas of injury are identified.
– establish IV line for fluid replacement - To assess wounds and injuries
a. two large – IV bone catheters insertion immediately
G18 – Green – BT/OR G24 – yellow - pedia

G20 – pink - OB G26 – purple -

newborn
G22 – blue –
Adult/IM
SECONDARY SURVEY
- Complete health history B. HEAT EXHAUSTION
- Head-to-toe assessment (includes Exhibit:
reassessment of airway, breathing and VS)
- Diagnostic and Lab testing 1. high body temp
- Application of monitoring devices (ECG, 2. headache
arterial lines, urinary cath) uo
UO Formula: (o.5 -1ml/kg/hr) 3. anxiety
- Splinting of suspected fractures 4. syncope (fainting)
- Cleansing, closure and dressing wounds
5. profuse diaphoresis
- Performance of other necessary
interventions based on the pt’s condition 6. gooseflesh (goosebumps)
I. ENVIRONMENTAL EMERGENCIES 7. orthostasis (orthostatic hypo)
1. Heat-induced illnesses Management:
2. Hypothermia 1. Lie supine
3. Drowning 2. Cool environment
4. Snakebites 3. IV and Oral fluids
1. Heat-induced illnesses C. HEAT STROKE
- Caused by prolonged exposure to environmental - Most serious heat induced illness
heat leading to loss of electrolytes - Acute medical emergency
- Caused by failure of the heat-regulating
mechanisms of the body
- Associated with dehydration
Most common cause: Non-exertional, prolonged
exposure to an environmental temp >39.2 deg.
cel and a heat index of >35 deg. cel
Assessment

<38C >38C >39.2C - Profound central nervous system (CNS)

dysfunction, manifested by: confusion,
delirium, bizarre behavior, coma, seizure
A. HEAT CRAMPS - Elevated body temperature: 40.6 deg cel
or higher
Has 3 cardinal manifestation: - Hot, dry skin usually anhidrosis (no sweating)
1. Muscle cramps (shoulder, abdomen, LE) - Hypotension, tachycardia, tachypnea
2. Diaphoresis Severe DHN hypo shock
3. Thirst Management
Duration
Main goal: Reduce high body temp asap = Mortality

Management: 1. remove pt’s clothing

1. Lie supine metabolism heat 2. core (internal) temperature is reduced to 39C
as rapidly as possible, preferably within 1 hr
2. cool environment
Methods:
3. Oral sodium supplements (hydration)
a. Cool sheets and towels: continuous sponging
4. Oral electrolytes solutions
– TSB (nurse), based on theory = SO
b. Cooling blankets
c. Immersion of the pt in a cold water bath
“optimal method of cooling” - heat temp
During cooling procedure:
- An electric fan is positioned so that it
blows on the pt: faster dissipation of heat
by convection & evaporation
- Pt temp is constantly monitored with a
thermostat placed in the ________ ,
__________ and ________ to evaluate
core
- temperature
- Cooling process should stop at 38C in
order to avoid iatrogenic -hypothermia
II. Hypothermia
- A condition in which the core (internal)
body temperature is 35C or less
- Cause: loss of the body’s
thermoregulation
- Emergency and life-threatening
III. Nonfatal Drowning
- Survival from potential drowning
- The majority of drowning events occur in
lakes, pools and bathtubs.
Prevention
- Avoiding rip currents offshore
- Surrounding the pool with fencing
- Self-latching/closing gate
- Providing swimming lessons
- Personal floatation device
*Supervision is still the best prevention measure
Major Complications
- After resuscitation:
- Pulmonary injury depend on the type of
fluid aspirated
• Freshwater – result in a loss of
surfactant leading to inability to
expand the lung
• Salt-water – pulmonary edema
from the osmotic effects of salt
within the lungs
Management
1. The factor with the greatest influence on
survival: Immediate CPR
2. Treatment goal: Prevent Hypoxia
3. Rectal probe
4. Indwelling FBC to monitor UIq
5. ECG monitoring
6. NGT for decompression –
IV. SNAKEBITES
- venomous snakebites are medical
emergencies
- The most common site is the: Upper E.
 Envenomation – injection of
venomous material
Classic clinical signs of envenomation:
1. Edema
2. Ecchymosis
3. Hemorrahic Bullae
Management
- no one specific protocol for tx of snakebite
- remove constrictive items Edema
Generally NOT used during the acute stage
a. ice, tourniquets,
b. heparin anticoagulant
c. corticosteroids immune suppressants
Antivenin – antitoxin manufactured from the
snake venom and used to treat snakebites
- Assessment of progressive s & sx is
essential before the administration of
antivenin
- Most effective given within 4-6 hours post
bite= 12 hrs
- Serum sickness is a type of
hypersensitivity response: before
administering antivenin and every 15mins
thereafter, the circumference of the
affected part is measured
- Can be given ___ or ____
- Depending on the severity of the
snakebite, antivenin is diluted in 500 or
1000 mL NSS
- Infusion is started slow then the rate is
increased after _10mins if no reaction
- The total dose should be infused during
the first 4-6 hrs after the bite.
- The initial dose is repeated until sx
decrease
- There is NO limit to the number of
antivenin vials that can be given.
 - The initial dose is repeated until sx A – aim at the base
decrease S – squeeze the handle
- Serum sickness is a type of
hypersensitivity response: before S – sweep from side to side
administering antivenir and every 15 mins Assessment: Extent of Surface Area burned
thereafter, the circumference of the
affected part is measured ▪ Rules of 9’s
– most
common
Blood Transfusion = 15 mins (needs close method to
monitoring) estimate
Transfusion rate= 20-40 drops per minute for 4 total body
hrs surface area
(TBSA);
divides the
BURNS body into
multiples of nine
– caused by a transfer of energy from a heat
source to the body
Classifications
▪ According to Cause:
1. Thermal burn – flame, scald, hot objects
2. Chemical burn – acid (household cleaners)
3. Smoke & inhalation – carbon monoxide,
hot air, steam smoke
4. Electrical burn – electric current
5. Radiation burn – sunburn
Burn phases and Management:

▪ According to Depth: 1. Emergent/ Resuscitative phase

Cell
- first 48 hrs after burn
Degree of burn Affectation Skin Pain
presentation
damage Characterized by: Fluid Shifting (IVC – ISC)
1st degree Epidermis Red, Intact Painful FVD
2nd degree
✔Manifestations:
Dermis Blister, Moist Painful
Surface

rd
3 degree Subcutaneous
layer
Pearly white Painless
a. Hypovolemnia
4th degree Muscles and Blackish, Charred Painless b. Hemoconcentration HCT FVD
bones
c. Generalized DHN
d. Oliguria Fluid
e. Hyperkalemia & Hyponatremia shifting
1st and 2nd: Partial Thickness Burn
f. Metabolic Acidocis
3rd and 4th: Full Thickness Burn g. Curling’s Ulcer – massive physiologic stress
Priorities in case of fire
R – remove the client Characterized by:
A – activate the alarm
✔ Manifestation:
C – confine the fire
E – extinguish fire a. Hypovolemia
b. Hemoconcentration
c. Generalized DHN
✔ How to use fire extinguisher:
d. Oliguria
P – pull the pin e. Hyperkalemia & Hyponatremia –
 f. Metabolic Acidocis – - removal of necrotic tissue from area of
g. Curling’s Ulcer – burns;
c. Wound Grafting
✔ Management
- decrease risk of infection
1. Priority: Airway ( burn wound = 2 deg - improve appearance
considetation) ● Autograft – most common; donor site comes
- Assess for breath sound, RR & singed hair from self
- Est open airway – 100% O2
- Adm oxygen therapy – carbon dioxide
inhalation 3. Rehabilitation Phase
> hgb has 200 greater affinity to CO than O2
✔ Management: Long term

1. Wound healing – incorporate physical

2. Fluid Resuscitation therapy exercises
- Insert large IV bore catheter 2. Restoration of ADL –
- Insert indwelling FBC 3. Psychosocial support –
3. Pain relief – morphon sulfate via IV DISASTER NURSING
4. Curling’s ulcer – adm antacids & h2 blockers TRIAGE CATEGORIES
5. Elevate burned extremities In a disaster, when HCP are faced with a large
number of casualties, the fundamental principle
guiding resource allocation is to do good for the
2. Acute/Intermediate phase – diuretic stage greatest number of people
After 48-72 hrs after burn reoccurrence of
capillary integrity
The North Atlantic Treaty Organization (NATO)
Characterized by: Triage system
- Most widely used triage category
✔ Manifestation:
- Consist of four colors: red, yellow, green
1. Hypervolemia and blue, each color signifies a different
2. Hemodilution - HCT Na remain level of priority
3. Diuresis trapped in ISC b
4. Hypokalemia & Hyponatremia FIELD TRIAGE the NATO triage sstem
5. Metabolic acidosis
Triage Category:
✔ Management: - life threatening BLACK
- Survivable with minimal intervention/ resources
1. Priority: Wound care and closure
RED
a. Wound Care
Priority: 1
• Open method – wound area is left
exposed after application of antibiotic Color: RED “immediate”
• Semi-open – wound is covered with thin Typical conditions: suckin chest wounds, airway
layer of sterile gauze after antibiotic obstructiom, secondary tp mechanical cause,
• Closed method – wound is covered with shock, hemothorax, tension pneumothorax,
thick layer of sterile gauze or occlusive asphyxia, unstable chest and abdominal wounds,
dressing after antibiotic incomplete amputations, open fractures of long
b. Wound Debridement eschar bones, and 2nd/3rd degree burns of 15-40% total
body surface
YELLOW
- injuries are significant and require medical care
- but can wait hours without treat to life or limb
PRIORITY: 2
COLOR: YELLOW “DELAYED”

Typical conditions: Stable abdominal wounds

without evidence of significant hemorrage; soft
tissue injuries; maxillofacial wounds without
airway compromise; vascular injuries with
adequate collaterak circulation; genitourinary
tract disruption; fractures requiring open
reduction, debridement and external fixation;
most eye CNS injuries
GREEN
- injuries are minor
- treatment can be delayed hours to days (move
away from main triage area)

PRIORITY: 3
COLOR: GREEN “minimal”
TYPICAL CONDITIONS: Upper extremity fractures,
minor burns, sprains, small lacerations without
significant bleeding, behavioral disorders or
psychological problems

BLACK
- injuries are extensive
- chances of survival are unlikely even with
definitive care

PRIORITY: 4
COLOR: BLACK “expectant”

Typical conditions: Unresponsive patients with

penetrating head wounds, high spinal cord
injuries, wounds involving multiple anatomical
sites and orans, 2nd/3rd burns in excess of 60% of
body surface area, seizures and vomiting within
24hr after radiation exposure profound shock
with multiple injuries, agonal respirations; no
pulse, no BP, pupils fixed and dilated