1. FIRST AID and EMERGENCY NURSING
University of Tabuk Faculty of Applied Medical Sciences Department of Nursing
FIRST AID and EMERGENCY NURSING

2. TRIAGE
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Department of Nursing

3. The word triage is derived from a French word that means “to sort
The word triage is derived from a French word that means “to sort.” In emergency care, triage is a process that is used to determine the severity of a patient’s illness or injury.
Department of Nursing
Department of Nursing

4. Triage is performed in both the pre-hospital and hospital environments.
Triage is a fluid process and is based on the number of patients, the amount of resources available, and the care that is available.
Triage is an important component of emergency nursing practice as patient censuses continue to increase and more has to be provided with less.
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Department of Nursing

5. Goals of Triage
• Early and brief patient assessment • Determination of the patient’s urgency for care • Documentation of findings • Control of patient flow through the emergency department • Assignment of patients to the appropriate care area • Initiation of diagnostic measures • Initiation of limited therapeutic interventions • Infection control • Promotion of public relations • Health education for patients and families
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Department of Nursing

6. Types of Triage
The type of triage that is used in an emergency department is dependent on several things including patient census, department layout, and number and type of staff.
As previously stated, triage is usually performed by an experienced registered nurse.
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7. Department of Nursing
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8. Components of Triage
Triage begins with an “across the room assessment.” This involves what the triage nurse sees, smells, or sometimes even feels when first evaluating the patient. For example: • Is the patient’s airway open or is he drooling? • Is the patient breathing and, if so, is the breathing effective? • What is the patient’s skin color: normal, pale, flushed? • Are there any obvious signs of illness or injury?
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Department of Nursing

9. Gerontological Considerations
Adults who were 70 years of age or older used approximately 70% of the total bed days, and in 2005, those 75 years of age and older had an ED admit
Rate of approximately 37%, compared to an average admit rate for all ages of 15% (Sendecki, 2007).
For this reason the hospital need to develop a course that applied geriatric/geropsychiatric knowledge, skills, and abilities the ED nurse can implement into their daily practice.
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Department of Nursing

10. Department of Nursing
Department of Nursing

11. A minimal amount of information should be gathered about why the patient has presented to the emergency department. Several mnemonics can be used to gather data depending on the patient’s chief complaint or reason why she came to the emergency department. The following pages contain mnemonics that can assist with collecting historical data in triage. Even though the CIAMPEDS mnemonic is directed more at collecting data for a pediatric patient, it can easily be adapted for the adult patient as well
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12. Department of Nursing
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13. Department of Nursing
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14. A brief, but focused physical assessment should be performed.
Objective data can be collected by using a primary assessment that includes airway, breathing, circulation, and disability.
A secondary assessment may be required in some cases to better differentiate the severity of a patient’s condition.
The secondary assessment should include exposure with environmental control, a full set of vital signs and family presence, provision of comfort, additional history, and a head-to-toe assessment as needed using inspection, palpation, and auscultation.
Department of Nursing
Department of Nursing

15. Triage Urgency Categories
Once an initial evaluation has been made related to the patient’s physical condition and chief complaint, the triage nurse will assign the patient an urgency category. Urgency categories rate patient acuity and assist in prioritizing care. Generally, an emergent patient is one who has an immediate life-threatening problem, for example, an airway obstruction. An urgent patient can wait a little longer, but would need to be seen as soon as possible. An example is a patient with chest pain, cardiac risk factors, and stable vital signs. Finally, a non-urgent patient can wait for care.
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Department of Nursing

16. Department of Nursing
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17. Three categories of ED TRIAGE
2 SYSTEM OF TRIAGE
1. ED Triage 2. Field Triage
Three categories of ED TRIAGE
Emergent- has the highest priority, conditions are life threatening, and they must be seen immediately.
Urgent- has serious health problems, but not immediately life threatening ones: they must be seen within 1 hour.
Non- urgent- has episodic illness that can be addressed within 24 hours without any increasing
morbidity.
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Department of Nursing

18. FIELD TRIAGE
Used during disaster. When health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is “To do the greatest good for the greatest number of people.” Decisions are based on the likelihood of survival and consumption of available resources.
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19. North Atlantic Treaty Organization (NATO) is the widely used triage system. It consist of 4 colors and signifies different level of priority.
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20. Triage Categories Color Priority Typical Condition
Immediate – Injuries are life threatening but survivable with minimal intervention.
Individual in this group can progress rapidly to expectant if treatment is delayed
Delayed – Injuries are significant and require medical care but can wait hours without threat to life.
Minimal –-Injuries are minor and treatment can be delayed hours to days
 Expectant – Injuries are extensive chances of survival are unlikely even with definitive care.-Comfort measures should be given
Red
Yellow
Green
Black 1    2 3 4
Sucking chest wound, Pneumothorax,
Incomplete amputation, unstable abdominal wound.
Stable abdominal wound without evidence hemorrhage, fracture requiring open reduction, debridement and external fixation
 Minor burns, sprains, small lacerations without bleeding, upper extremity fixation, psychological disturbance.
Unresponsive patient, profound shock, agonal respiration, fixed dilated pupils, negative pulse and BP.
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Department of Nursing

21. It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first?
A. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade
B. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed.
C. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed.
D. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
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