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EMERGENCY

NURSING
TRIAGING

Method of
patient care according to:

TRIER
meaning
to sort.
TRIAGING
Level 1 Resuscitation Need of immediate nursing
and medical attention
Level 2 Emergent Need immediate nursing
assessment and rapid
treatment
Level 3 Urgent
NON-LIFE
THREATENING
Can wait for 30 minutes
Level 4 Less urgent Can wait for 1 hour
Level 5 Non-urgent Can wait for 2 hours
FAST-TRACK:
first aid or basic
primary care in the
ED or a clinic or
physician's office

TRIAGING
Level 1
Need of immediate
nursing and medical
attention
Cardiopulmonary arrest
Major trauma
Seizures
Level 2
Need immediate
nursing assessment
and rapid treatment
Head injuries
Chest pain, stroke
Asthma, sexual assault
Level 3
Can wait for 30
minutes
Signs of infection, mild distress
and moderate pain
Level 4
Can wait for 1 hour Earache, chronic back pain,
upper respiratory symptoms,
mild headache
Level 5
Can wait for 2 hours Sore throat, menstrual cramps
TRIAGING
LEVEL 3:
requires two or
more resources
(
LEVEL 4:
one resource
only

RESOURCES
1. imaging studies
2. medications
administered by
intravenous (IV)
3. intramuscular (IM)
routes
4. invasive
procedures
TRIAGING
NOTES:
1. If you cant decide which TRIAGE
level is BEST for the patient: assign
in the HIGHER LEVEL
2. MAINTAIN COMMUNICATION:
patient status may change

TRIAGING
ROUTINE
ORDINARY times
PRIORITY: MOST
CRITICALLY ILL,
regardless of
potential outcome
FIELD
disasters and mass
casualty incidents
scarce resources
must be used to
BENEFIT THE MOST
PEOPLE POSSIBLE
TRIAGING
TRIAGE CATEGORY PRIORITY COLOR TYPICAL CONDITIONS
IMMEDIATE:
life-threatening but
survivable with minimal
intervention.
can progress rapidly to
expectant
1 Red Sucking chest wound, airway
obstruction, shock,
hemothorax, 2nd/3rd degree
burns of 15%40% total body
surface area
DELAYED
require medical care, but
can wait hours
2 Yellow Stable abdominal wounds
without evidence of
significant hemorrhage;
MINIMAL:
minor and treatment can
be delayed hours to days.
3 Green minor burns, sprains, small
behavioral disorders or
psychological disturbances.
EXPECTANT:
survival unlikely
4 Black Unresponsive patients with
penetrating head wounds,
high spinal cord injuries,
DISASTER LEVELS

DECONTAMINATION
STEPS:
1. Removal of the patient's clothing
and jewelry and then rinsing the
patient with water.
2.Thorough soap-and-water wash and
rinse.

TYPES OF WEAPONS OF TERROR:
biological
chemical
radialogic
CHEMICAL
CHARACTERISTICS:
1. VOLATILITY (tendency for a chemical to
become a vapor)
2. PERSISTENCE (likelihood to vaporize and
disperse)
3. TOXICITY (potential of an agent to cause
injury to the body)
4. LATENCY (time from absorption to the
appearance of symptoms)
RADIOLOGIC
TYPES OF RADIATION
TYPE EFFECT REMARKS
Alpha particles Cannot penetrate
the skin
Localized damage
Beta particles Moderately
penetrate the skin
Skin damage if
prolonged

Gamma-radiation
(X-rays an example )
Penetrating Difficult to shield
RADIOLOGIC
TYPES OF INJURY
TYPE EXPOSURE REMARKS
External
irradiation
all or part of the
body
not radioactive
Contamination externally or
internally
immediate medical
management
Incorporation actual uptake of
radioactive
material
Vital organs
involved
RADIOLOGIC
PHASES OF EFFECTS OF RADIATION EXPOSURE
Prodromal phase
(4872 hr after
exposure)
GI UPSET; fatigue (High-dose radiation) fever,
respiratory distress, and increased excitability
Decreasing lymphocytes, leukocytes, thrombocytes,
red blood cells
Latent phase (last
up to 3 week)
Decreasing lymphocytes, leukocytes, thrombocytes,
red blood cells (symptom-free )
Illness phase Infection, fluid and electrolyte imbalance,
bleeding, diarrhea, shock, and altered level of
consciousness
Recovery phase Can take weeks to months for full recovery
Death Increased intracranial pressure is a sign of
impending death
RADIOLOGIC
SURVIVAL
PROBABLE (no initial
symptoms or only minimal
symptoms does not persist)
POSSIBLE (with nausea and
vomiting that persists for 24
to 48 hours. lymphocyte
count is less than 1200/mm
3
)
IMPROBABLE (received
more than 800 rad of total
body penetrating
irradiation)
PERSONAL PROTECTION:
ESSENTIAL


an act of omission or commission
4DS
Duty for nurse
Dereliction (breach of duty)
Damages as result
Direct result (injury, harm or
death)
AN ACT TO PROMOTE DONATIONS IN GOOD FAITH
OF MEDICINES, FOOD PRODUCTS OR SUPPLIES BY
ESTABLISHMENTS AND OTHER ENTITIES,
INCLUDING INDIVIDUALS BY EXEMPTING THEM
FROM ANY FORM OF LIABILITY ARISING
THEREFROM


protects private citizen
provides aid without undue fear of litigation
protects EMT from civil charges
doesnt protects EMT from gross negligence
Senate Bill No. 1917
Consent

principle: AUTONOMY/Self Determination
consent not possible;
- disoriented
- minors with no parents available
- mentally handicapped
Two types:
a. Expressed/Informed
b. Implied
**emancipation as an exemption


Refusal of Treatment & Transport

Challenges..
each person has the right to
refuse (competent)
has the right to withdraw
treatment
issue is false imprisonment
issue on Assault & Battery






Interventions..
explain consequences &
alternatives
try to convince victim to
accept care transport
sign: refusal treatment release
form
use best judgement whether
victim has mental incompetence



Other issues

Abandonment
EMT leave victim without
giving opportunity for continued
care
EMT must prove patient
refused
charges possible of patient
refusing is incompetent






Intoxicated, Irrational
& Emotionally
disturbed..
high legal risk
two solutions;
a. protective custody
b. forcible removal




Other issues


Resuscitation Issue;
Proxies
Extended Transport
- If patient dies during transport
1. Ambulance must stop
2. Inform coroner





Donor & Organ Harvest;
advance directives
- divers license
-separate donor card
- Communicate info w/
medical director




One of the most important role in EMS
- receives the call for help
- dispatches 1
st
responder & EMS
- coordinate emergency response
- relay information from prehospital to
hospital


Characteristics:
Accurate
Confidential
Use of systemic approach to collect information
Ability to calm people
Ability to express empathy & care


Types:
a. Radio via repeater
1) Base station radio
2) Mobile two-way radios
3) Hand-held/portable radios
4) Biotelemetry
b. Cellular phones



Process:
1. Receive call for help
2. Dispatch appropriate units
3. Provide updates/clarification
4. Dispatch additional resource as
needed
5. Provide pre-arrival information





When to communicate
when call received
when unit begins response
On arrival at scene
When leaving the scene
On arrival at hospital
When leaving the hospital
When return to station or post
When unit available for next
assignment




Fast Facts:
Victim & Family Intervention
Patient
allow patient to express
feelings
do not contradict if
patient indicates death
imminent
do not offer false
assurance
listen empathically
provide respect, privacy,
dignity, sense of control
allow DABDA to run its
course


Family

assess knowledge
constantly inform
allow family to travel
with patient
If family refuses
treatment, inform the
medical director





Pre-hospital Care Report (PRC)
Valuable part of patient record
Documents all aspects of call
Important part of legal record





a. Run (dispatch) data
Date, time of call (military time)
Crew responding
Type of call
Sequential time of response
Route, cross streets, major thoroughfares
Nature of problem stated in call





b. Patient data
Basic information
If become unconscious PRC data becomes main
information source
c. Assessment data
Critical signs & symptoms
Chief complains
Vital signs
Mental status
Skin assessment
Objective & subjective findings





d. Treatment data
Treatment with time relationship
Treatment rendered before arrival
Transport method
Hospital notification
Type of receiving facility
e. Patient Disposition
Receiving hospital
Special transport method
Final disposition of patient at hospital
Signature of EMT, receiving nurse/physician





Death;
Irreversible or obvious death
Clinical declaration needed
Record factors of death
General statements such as DOA not acceptable
Time of death
DNR order noted
Dying statement: EMS becomes sole witness
Homicide & Suicide;
Do not disturb crime scene
Do not move body
Report criminal act to police




Up next
Body mechanics