Illinois EMSC1 Assessment and Triage Objectives Upon completion of this lecture, you will be better able to: Discuss the importance of performing a systemic, prioritized initial assessment Describe the 4 components of the initial assessment Compare and contrast the 3 categories of triage Apply the principles of initial assessment to make accurate triage decisions in selected case studies

Illinois EMSC2 ASSESSMENT AND TRIAGE

Illinois EMSC3 Considerations in Initial Assessment History and physical assessment can be simultaneous NOTE: The assessment process is stopped to initiate life-saving measures (CPR) Cultural and other factors may affect the assessment process

Illinois EMSC4 INITIAL ASSESSMENT Scene safety assessment “Across–the-room assessment” Brief physical assessment Brief health history

Illinois EMSC5 “ACROSS-THE-ROOM ASSESSMENT” General appearance Airway status Work of breathing Circulatory status Disability (neurological) status

Illinois EMSC6 SCENE SAFETY ASSESSMENT SELF People Environment

Illinois EMSC7

8 BRIEF PHYSICAL ASSESSMENT Airway Breathing Circulation Disability Expose/examine Fahrenheit Get vital signs Head-to-toe assessment Isolate

Illinois EMSC9 BRIEF HEALTH HISTORY Chief complaint Immunizations/isolation Allergies Medications Past health history Events surrounding the current problem Diet Symptoms associated with the current problem

Illinois EMSC10 BRIEF HEALTH HISTORY SAMPLE SYMPTOMS ALLERGIES MEDICATIONS PAST HISTORY LAST MEAL EVENTS LEADING TO THE ILLNESS OR INJURY

Illinois EMSC11 INTERVENTIONS Interventions are guided by the school nurse’s assessment of the student’s health problem Interventions are based on the school nurse’s guidelines for practice or standing orders.

Illinois EMSC12 TRIAGE AND TRANSPORT Dependent upon the school nurse’s assessment and interventions Dependent on the IEMP and school emergency plan

Illinois EMSC13 TRIAGE

Illinois EMSC14 TRIAGE CONSIDERATIONS Establish triage guidelines Initial triage category can be upgraded or downgraded depending on student response “Gut reaction” or “sixth sense” should be trusted Overtriage is acceptable Designate experienced RN’s for triage Reassessment is necessary and essential Maintain emergency skills/knowledge Triage also used in multicasualty situations

Illinois EMSC15 TRIAGE CATEGORIES EMERGENT URGENT NON-URGENT

Illinois EMSC16 EMERGENT CONDITION IS LIFE-THREATENING CARE MUST BE INITIATED IMMEDIATELY

Illinois EMSC17 EMERGENT Example – Gun Shot Wound to the Chest

Illinois EMSC18 URGENT Condition is severe but not life-threatening. It requires medical intervention within two hours but not immediate care.

Illinois EMSC19 URGENT Wrist fracture without neurovascular compromise Dog bite to the ear

Illinois EMSC20 NON-URGENT Condition is non-acute or minor Care can be delayed for hours

Illinois EMSC21 NON-URGENT Example – Minor cut to the lower lip

Illinois EMSC22 TRIAGE PROCESS Initial assessment Triage decision Plan of care Intervention Evaluation Outcome/disposition

Illinois EMSC23 TRIAGE AND TRANSPORT EMERGENT - Status asthmaticus or worsening respiratory distress URGENT - No improvement with treatment NON-URGENT - Improvement with treatment and absence of respiratory distress

Illinois EMSC24 OUTCOME/DISPOSITION Return to class Observe in health office Transport to home, physician’s office or ED with a reliable parent/guardian Transport to ED by air or EMS

Illinois EMSC25 EVALUATION AND FOLLOW-UP School health record Hospital/primary care provider Prehospital personnel

Illinois EMSC26 PREVENTION Recognize and report dangerous areas in the school Maintain current health records Teach others how to recognize communicable diseases Collect and monitor data related to injury and illness Share critical IEMP information with faculty and aides

Illinois EMSC27 Summary One of your primary responsibilities as a school nurse is to recognize severe illness or injury among students, using a systematic, consistent assessment approach. Appropriate triaging is based on this assessment and guided by triage protocols and policies.

Illinois EMSC28 ANY QUESTIONS??