No. Nursing Action Performed?

(Yes/No) Time Notes

1.1 Initial ABCDE assessment completed (Airway, Breathing, Circulation, Disability, Exposure) ☐ Yes ☐ No _____
1.2 Vital signs monitored and documented (HR, BP, RR, SpO₂, Temp, GCS) ☐ Yes ☐ No _____
1.3 Exposure assessment: removed contaminated clothing, skin/eye decontamination performed if needed ☐ Yes ☐ No _____
1.4 History taken: substance, time, route, amount, intent (suicidal/accidental) ☐ Yes ☐ No _____
1.5 Toxidrome assessed (e.g., opioid, anticholinergic, sympathomimetic) ☐ Yes ☐ No _____
1.6 Activated charcoal administered (if indicated and no contraindications) ☐ Yes ☐ No _____
1.7 Antidote prepared/assisted with administration (e.g., Naloxone, NAC, Flumazenil) ☐ Yes ☐ No _____
1.8 Specimen collection: blood (paracetamol, salicylate, ethanol, ABG), urine (tox screen) ☐ Yes ☐ No _____
1.9 ECG performed and reviewed for arrhythmias/QT prolongation ☐ Yes ☐ No _____
1.1 Continuous monitoring initiated (cardiac, SpO₂, neurological status) ☐ Yes ☐ No _____
1.11 Mental health/suicide risk screening completed (if applicable) ☐ Yes ☐ No _____
1.12 Patient and family educated about poisoning and treatment ☐ Yes ☐ No _____
1.13 Consultation with Poison Control or medical team initiated ☐ Yes ☐ No _____
1.14 Accurate and timely documentation in nursing notes ☐ Yes ☐ No _____
1. Poisoning Management – Nursing Assessment & Interventions

Emergency Triage Protocol – Nursing Adherence

No. Nursing Action Performed? (Yes/No) Time Notes
No. Triage
2.1 Nursing Action within 5 minutes of arrival (immediately for critical cases)
completed ☐Performed?
Yes ☐ No (Yes/No) Time
_____ Notes
3.1 Primary survey (ABCDE) performed and documented ☐ Yes ☐ No _____
2.23.2Standardized triage tool
Airway managed: usedavailable,
suction (e.g., ESI,intubation
CTAS, ATS)assisted, O₂ delivered as ordered ☐☐Yes ☐☐
Yes NoNo _____
_____
3.3 Oxygen therapy initiated with appropriate delivery device and SpO₂ monitoring ☐ Yes ☐ No _____
2.3 Triage level clearly documented in system/chart ☐ Yes ☐ No _____
3.4 At least one large-bore IV access established ☐ Yes ☐ No _____
2.43.5Vital signs
Fluid (HR, BP, RR,initiated
resuscitation SpO₂, Temp, GCS) measured
per protocol andfor
(e.g., bolus recorded
shock) at triage ☐☐Yes ☐☐
Yes NoNo _____
_____
3.6 Vasopressor/inotrope infusion initiated and monitored (e.g., norepinephrine) ☐ Yes ☐ No _____
2.5 Red flags identified (e.g., chest pain, altered mental status, overdose, trauma) ☐ Yes ☐ No _____
3.7 Continuous monitoring in place (ECG, SpO₂, NIBP, temperature) ☐ Yes ☐ No _____
2.63.8Immediate
Point-of-care tests performed
escalation (glucose,
for high-acuity lactate,
patients (e.g.,Hb)
Code Red, Rapid Response) ☐☐ Yes
Yes ☐☐NoNo _____
_____
3.9 Critical interventions supported (e.g., CPR, defibrillation, trauma care) ☐ Yes ☐ No _____
2.73.1Time to physiciancare
Time-sensitive assessment
supportedaligned
(e.g.,with
stroketriage
code,level
sepsis bundle) ☐☐Yes ☐☐
Yes NoNo _____
_____
2.8 Re-triage performed if patient deteriorates or wait timeprecautions)
3.11 Patient safety maintained (side rails, fall risk, seizure exceeds threshold ☐☐ Yes
Yes ☐☐NoNo _____
_____
3.13 Family updated on patient status (when appropriate) ☐ Yes ☐ No _____
2.9
3.14Triage nurse prepared
Handover certified/trained in local triage
using SBAR/ISBAR for system
shift change or transfer ☐☐Yes ☐☐
Yes NoNo _____
_____
2.1 Triage documentation complete, legible, and time-stamped ☐ Yes ☐ No _____
Emergency & Critical Care – Nursing Assessment & Managemen