Assessment and Triage Objectives

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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

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ASSESSMENT AND TRIAGE
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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

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INITIAL ASSESSMENT

• Scene safety assessment
• Acrossthe-room assessment
• Brief physical assessment
• Brief health history

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ACROSS-THE-ROOM ASSESSMENT

• General appearance
• Airway status
• Work of breathing
• Circulatory status
• Disability (neurological) status

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SCENE SAFETY ASSESSMENT

• SELF
• People
• Environment

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BRIEF PHYSICAL ASSESSMENT

• Airway
• Breathing
• Circulation
• Disability
• Expose/examine
• Fahrenheit
• Get vital signs
• Head-to-toe assessment
• Isolate

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BRIEF HEALTH HISTORY

• Chief complaint
• Immunizations/isolation
• Allergies
• Medications
• Past health history
• Events surrounding the current problem
• Diet
• Symptoms associated with the current problem

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BRIEF HEALTH HISTORY

• SAMPLE
• SYMPTOMS
• ALLERGIES
• MEDICATIONS
• PAST HISTORY
• LAST MEAL
• EVENTS LEADING TO
  THE ILLNESS OR INJURY

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INTERVENTIONS

• Interventions are guided by the school nurses
  assessment of the students health problem
• Interventions are based on the school nurses
  guidelines for practice or standing orders.

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TRIAGE AND TRANSPORT

• Dependent upon the school nurses assessment and
  interventions
• Dependent on the
  IEMP and school
  emergency plan

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TRIAGE
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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 RNs for triage
• Reassessment is necessary and essential
• Maintain emergency skills/knowledge
• Triage also used in multicasualty situations

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TRIAGE CATEGORIES

• EMERGENT
• URGENT
• NON-URGENT

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EMERGENT

• CONDITION IS LIFE-THREATENING
• CARE MUST BE INITIATED IMMEDIATELY

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EMERGENTExample Gun Shot Wound to the Chest
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URGENT

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

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URGENT
Dog bite to the ear
Wrist fracture without neurovascular compromise
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NON-URGENT

• Condition is non-acute or minor
• Care can be delayed for hours

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NON-URGENT Example Minor cut to the lower lip
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TRIAGE PROCESS

• Initial assessment
• Triage decision
• Plan of care
• Intervention
• Evaluation
• Outcome/disposition

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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

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OUTCOME/DISPOSITION

• Return to class
• Observe in health office
• Transport to home, physicians office or ED with
  a reliable parent/guardian
• Transport to ED by air or EMS

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EVALUATION AND FOLLOW-UP

• School health record
• Hospital/primary care provider
• Prehospital personnel

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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

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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.

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ANY QUESTIONS??