Prepared by: Salwa MaghrabiTeacher assistant

Nursing Department

Definition of triage .

The personal abilities that are essential to be an effective triage nurse

Daily triage in hospital setting .

Hospital triage system :

Emergent category . Urgent category. Nonurgent category

Triage process :

The gathered information at point of triage .

The initial assessment at point of triage .

Identify the triage .

Count the characteristics to be an effective triage nurse .

Mention the purpose of daily triage in hospital setting .

List and differentiate between the categories of hospital triage system.

Understand the triage process .

It is the process which places the right patient in the right place at the right time to receive the right level of care.

Accurate triage allow the nurse to do the greatest good for the greatest number of afflicted .

Clinically experience . Good judgment and leadership . Calm and cool under stress. Decisive . Knowledgeable of available resource .

Sense of humor . Creative problem solver . Availability . Experienced and knowledgeable

regarding anticipated casualties .

Nurses perform daily triage on a routine bases every day in the emergency department .

The purpose :

Is to identify those patient who have the highest degree of compromise for the purpose of providing rapid care to the sickest patient first .

I) I) Emergent CategoriesEmergent Categories

Definition Time needed Example

Those that are life threatening , but likely to be amenable to rapid intervention that does not require an inordinate amount of resources .

requires treatment immediately or within 15 to 30 minutes .

•Cardiac arrest . •Airway obstructions . •Hemorrhage with shock .•Complicated delivery. •Seizure •Asthma •A cute bleeding or acute pain . •Depressed level of consciousness.

II) II) Urgent CategoriesUrgent Categories

Definition Time needed Example

Those conditions that are serious and if not treated in timely manner , are likely to deteriorate to become critical .

serious illness or injury that must be attended to, but wait of up to 2 hours

•Complex long bone fracture .•Bleeding controlled with a pressure dressing.•A cute psychiatric problem •High fever with other vital signs stable

III) III) Nonurgent CategoriesNonurgent Categories

Definition Time needed Example conditions that can

wait without likelihood of deterioration .

conditions that can wait more than 2 hours.

- Minor laceration which require sutures.

- Minor joint trauma which requires an X- ray for diagnosis .

- Request for medication refills.

- Chronic conditions that are stable Such as preexisting skin rash

1- Gathering information at point of triage .

2- Perform initial assessment ( assessment sheet ) at point of triage .

The goal of triage process :

to gather sufficient data for

determining acuity, identify

immediate needs, and establish

a rapport with the patient and family.

Triage process should be completed within 5 minutes.

1 -THE GATHERED INFORMATION AT TRIAGE POINT

Name Age Gender Chief complain History of present illness Mechanism of injury Past medical or surgical history Allergies to food or medications . Current medications

1 -THE GATHERED INFORMATION AT POINT OF TRIAGE CONT’

Date of last tetanus immunization Last menstrual period (for female from age of 11

to 60). Vital signs : temperature , pulse ,blood pressure ,

respiratory rate. Skin vital signs : temperature , color , moisture ,

level of consciousness.

1 -THE GATHERED INFORMATION AT POINT OF TRIAGE CONT’

Visual inspection for deformities, laceration, bruising , rashes , etc .

Height and weight. Mode of arrival. Private medical provider .

22 - -The initial assessment The initial assessment ( assessment ( assessment

sheet )at the Point of Triagesheet )at the Point of Triage