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Assessment and Triage Objectives

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

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Assessment and Triage Objectives

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  1. 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 Illinois EMSC

  2. ASSESSMENT AND TRIAGE Illinois EMSC

  3. Considerations in Initial Assessment • History and physical assessment can be simultaneous • NOTE: Theassessment process is stopped to initiate life-saving measures (CPR) • Cultural and other factors may affect the assessmentprocess Illinois EMSC

  4. INITIAL ASSESSMENT • Scene safety assessment • “Across–the-room assessment” • Brief physical assessment • Brief health history Illinois EMSC

  5. “ACROSS-THE-ROOM ASSESSMENT” • General appearance • Airway status • Work of breathing • Circulatory status • Disability (neurological) status Illinois EMSC

  6. SCENE SAFETY ASSESSMENT • SELF • People • Environment Illinois EMSC

  7. Illinois EMSC

  8. BRIEF PHYSICAL ASSESSMENT • Airway • Breathing • Circulation • Disability • Expose/examine • Fahrenheit • Get vital signs • Head-to-toe assessment • Isolate Illinois EMSC

  9. BRIEF HEALTH HISTORY • Chief complaint • Immunizations/isolation • Allergies • Medications • Past health history • Events surrounding the current problem • Diet • Symptoms associated with the current problem Illinois EMSC

  10. BRIEF HEALTH HISTORY SAMPLE • SYMPTOMS • ALLERGIES • MEDICATIONS • PAST HISTORY • LAST MEAL • EVENTS LEADING TO THE ILLNESS OR INJURY Illinois EMSC

  11. INTERVENTIONS • Interventions are guided by the school nurse’s assessment of the student’s health problem • Interventions are based on the school nurse’s guidelines for practice or standing orders. Illinois EMSC

  12. TRIAGE AND TRANSPORT • Dependent upon the school nurse’s assessment and interventions • Dependent on the IEMP and school emergency plan Illinois EMSC

  13. TRIAGE Illinois EMSC

  14. 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 RN’s for triage • Reassessment is necessary and essential • Maintain emergency skills/knowledge • Triage also used in multicasualty situations Illinois EMSC

  15. TRIAGE CATEGORIES • EMERGENT • URGENT • NON-URGENT Illinois EMSC

  16. EMERGENT • CONDITION IS LIFE-THREATENING • CARE MUST BE INITIATED IMMEDIATELY Illinois EMSC

  17. EMERGENTExample – Gun Shot Wound to the Chest Illinois EMSC

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

  19. URGENT Dog bite to the ear Wrist fracture without neurovascular compromise Illinois EMSC

  20. NON-URGENT • Condition is non-acute or minor • Care can be delayed for hours Illinois EMSC

  21. NON-URGENTExample – Minor cut to the lower lip Illinois EMSC

  22. TRIAGE PROCESS • Initial assessment • Triage decision • Plan of care • Intervention • Evaluation • Outcome/disposition Illinois EMSC

  23. 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 Illinois EMSC

  24. OUTCOME/DISPOSITION • Return to class • Observe in health office • Transport to home, physician’s office or ED with a reliable parent/guardian • Transport to ED by air or EMS Illinois EMSC

  25. EVALUATION AND FOLLOW-UP • School health record • Hospital/primary care provider • Prehospital personnel Illinois EMSC

  26. 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 Illinois EMSC

  27. 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. Illinois EMSC

  28. ANY QUESTIONS?? Illinois EMSC

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