Triage categories
Priority client needs examples
Emergent immediate intervention is required to sustaion life or limp cardiac arrest multiple trauma
Urgent care is required within 1-2 hrs to prevent deterioration of condition compound fractures persistent vomitling and diarrhea
Nonurgent care may be delayed witjout risk of pre-manent sequelae -- contusolions minor sprains and fractures
Cetegories of the triage
Categories of triage separate , patients according to severity of injury . a special color coded tagging system is used during a MCI . so that the triage category is immediately obvious . there are several triage systems in use across the country and every nurse should be aware of the systems used by his or her facility and community .
Triage systems is one that is widely used , it consist of four colors (red , yellow , green , black ) each color signifies different level of priority .
Emergent: patients have the highest priority their conditions are life threatening. And they must be seen immediately.
Urgent patients : have serious problems , but not immediately life threatening ones , thy must be seen within i hour .
Non-urgent : patients have episodic illnesses that can be addressed within 24 hours without increased morbidity . Afourth increasingly used class is " fast - track " these patients require simple first aid or basic primaty care . Thy may be treated in the edor safely referred to a clinic or physician's office .
Triage is an advanced skill , emergency nurses spend msnu hours learning to classify different illnesses and injuries to ensure that patients most in need of care do not wait to receive it . Protocols may be gollowed to initiate laboratory or x-ray studies from the triage area while the patient waits for a bed in the ED. Collaborative protocols afe developed and used by the triage nursebased on his or her level of experience . Also , nurses in the triage area collect crucial initial data vital signs and history neurologic assessment findings and diagnostic data if neccessary .
Triage category priority colour typical conditions
Immediate injuried are life threatening but survivable with minimal intervention individuals in this group can progress rapidly to expactant if treatment is delayed
1 ]
red sueking chest wound , air wau obstruction .secondary to mechanical cause , shock , hemothorax , tension pneumothorax , asphyxia , unstable chest and abdominal wound , incomplete amputation , open fracture of long bones and 2 nd - 3 rd degree burn 15%- 40% total body surface area
Delayed: injuries are significant and require medical care but wait hours without threat to life or limb . Individuals in this group receive treatment only after immediate casualties are treated
2
yellow stable abdominal wound with out evidence of significant hemorrhage , soft tissue . Injuries maxillofacial wound without airway commpromise , vascular injuries with adequate collateral circulation . Genitourinary tract disruphion , fractures requiring open reduction debridement and external fixation most eye and central nervous system injuries
minimal : injuries are minor and treatment can be delayed hours to days . Individuals in this group should be moved away from the main triage area
3
green uper extremity fractures , minor bones , sprains , small laceration without significant bleeding behavoir disorders or psychological disturbance
Expactant : injuries are extensive and chance of survival are unlikely even with difinitive care . Persons in this group should be separated from other casualties but not abandonel comfort measures should be provided when possible
4
black --- unresponsive patients with penetrating head wound , high spinal cord injuries , wound involving multiple anatomic sites and organs , 2 nd - 3 rd degree burns in excess of 60% of total body surface area . Seizures or vomiting wihin 24 hours after radiation exposure , profound shock with multiple injuries and aspiration , no pulse , no blood pressure , pupils fixed and dilated
Start method of triage
Using to identify and separate patients rapidly , according to the severity of their injuries and their need for treatment the start system is designed to assist rescuers to find the most seriously injured patients . As mor rescue personnel arrive on the scene , the patient will be re-triaged for further evaluation , treatment , stabilization , and transportation . This system allows first respomders to open blocked airways and stop sever bleed ing quickly .
Start triage is intended to be completed in about 30 seconds per patient . Begin by asking all patient who can walk to get up and go to a collection point such as an ambulance or a building .since those who can do this are .
*conscious
*able to flow commands
*able to walk