EMERGENCY DEPARTMENT TRIAGE REVIEW

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1 EMERGENCY DEPARTMENT TRIAGE REVIEW Scenario: You work in a busy emergency department (ED) and are assigned as the triage RN for a 12-hour shift. After your initial assessment of each of the 4 clients in each of the 10 questions, which client would you take to a room immediately? Remember, as a triage nurse it is your responsibility, based on your assessment skills, to classify clients into 1 of 3 categories: Emergent, Urgent, and Non-urgent. The following definitions for these 3 categories will better help you answer these questions and get more right than wrong. Emergent Life-threatening illness or injury at time of arrival. Urgent Stable on arrival, but needing medical intervention in timely manner. Non-urgent- Stable on arrival; are not in immediate need of emergency treatment. It is also imperative to realize your limitations and know when to ask for assistance from other RN s if more than 1 emergent client presents that requires immediate intervention. Emergency Department Triage Review-Hurst Review Services 1

2 Place a checkmark by the category that best classifies the following clients. Place an asterick (*) by the client requiring immediate intervention. 1. A. A client with cough/congestion and productive sputum of yellow color x 1 week. Chest pain upon inspiration. SaO 2 98% on room air with respiratory rate of 18. Emergent Urgent Non-urgent B. A client who slammed her right index finger in a car door with no obvious deformity seen, but gross edema present. Cap refill < 2 sec. Limited range of motion. P 120, R 18, BP-142/87. Emergent Urgent Non-urgent C. 10 month-old infant with audible stridor, SaO 2 88% on room air. P -193, R Mother states infant reached in her purse and was found playing with coins. D. A client who bought his 12 y/o son a BB gun. While loading the BB gun for the first time, a malfunction occurred firing a BB pellet into the father s left calf. No active bleeding noted. All motor/sensory intact. Cap refill < 2 sec. Father denies paresthesias. + Dorsalis pedal pulse. P-72, R-20, BP-138/79. Emergency Department Triage Review-Hurst Review Services 2

3 2. A. A client reports sore throat, runny nose, and cold x 10 days. B. A client with history of bipolar disorder. States I feel angry and want to hurt someone. Prior to your initial triage assessment, client was yelling at other clients in the waiting room, claiming she was Jesus. C. A client reports urinary frequency and dysuria x 1 week. D. A client with chronic back pain. Was involved in a motor vehicle crash 10 years ago. Has had multiple back surgeries. Denies new injury. States ran out of pain medications. Emergency Department Triage Review-Hurst Review Services 3

4 3. A. A client reports shortness of breath on exertion, gradually progressive x 3 days. Denies chest pain. Ran out of Lasix 4 days ago. P- 99, R- 26, BP- 154/92. SaO 2 95% on room air. B. A client states, I just don t feel good. Denies pain or shortness of breath. No nausea or vomiting. Decreased appetite. Alert & oriented x 3. Color good/pink. T , P-92, R- 22, BP 160/100, SaO 2 99%. C. A client states, I have nowhere to go. Left personal care home 1 week ago. Denies pain. States, I m hungry. T- 98.7, P- 68, R- 18, 178/80. D. A client reports shortness of breath and chest heaviness x 30 min. prior to arrival. Denies nausea or vomiting or pain radiation. + diaphoresis. P-181, R- 42, BP-87/42, SaoO 2-91% on room air. Emergency Department Triage Review-Hurst Review Services 4

5 4. A. A 67 y/o client with sudden onset slurred speech, headache, and right-sided weakness 1 hour prior to arrival. Attempts to speak, but words are garbled. BP- 199/119, P-117, R-22, SaO 2-96% on room air. B. 5 y/o client with 1 inch laceration to forehead. Was jumping on trampoline and fell striking head on metal railing. Bleeding controlled. Witnessed by mom. Alert & oriented x 3. Mother denies loss of consciousness. T-98.5, P- 118, R-24, BP-80/54, SaO 2-99% on room air. C. A client reports severe generalized abdominal pain. No bowel movement x 1 week. History: lung CA. Last chemo treatment 4 days ago. Decreased appetite. T-100.0, P-102, R-18, BP 162/91, SaO 2-95% on room air. D. A client 1-week post-op hysterectomy. Denies pain, but reports yellow incision site. States site has come open. T-103, P-91, R-16, BP- 132/60. Emergency Department Triage Review-Hurst Review Services 5

6 5. A. Car pulls up outside of triage dumping a 16 y/o male on the sidewalk. Upon initial assessment you find a gun shot wound to abdomen. Client unresponsive, profuse hemorrhaging noted. B. A client with severe left-sided chest pain, shortness of breath, diaphoresis with heavy pressure radiating to left arm, neck, and shoulder. Client is clutching left side of chest. C. A truck-driver who drives a fuel truck reports gasoline splashed into eyes. States I can t see. D. A client with severe headache, history of chronic tension headaches and reports being under great deal of stress at home and work. Emergency Department Triage Review-Hurst Review Services 6

7 6. A. A client sliced left ring finger above nail bed at work. Full range of motion. Denies paresthesias. Cap. Refill < 2 seconds. Bleeding controlled. B. 3 month old infant with inconsolable crying. Mother states infant has been pulling on right ear x 1 day. T rectal, P-158, R-30, SaO 2-98% on room air. C. A client states glucose has been too high. Alert and oriented x 3. No diaphoresis. Ate lunch 1-hour prior to arrival. States, ran out of insulin. Capillary glucose finger stick in triage resulted a glucose of 267 mg/dl. T-98, P-99, R-18, BP 152/71. SaO 2 97% on room air. D. A client, 37 weeks gestation. States, My water broke. Also with moderate bleeding. Onset 45 minutes prior to arrival and abd. pain with contractions < 10 minutes apart. T-99, P-139, R-24, BP-180/110. Emergency Department Triage Review-Hurst Review Services 7

8 7. A. A client reports suprapubic abd. pain. Last menstrual period 2 months ago. Denies vaginal bleeding, or passage of clots. Admits to unprotected sexual intercourse approximately 1 month ago. Last bowel movement today was normal. T-98, P-74, R-16, BP-110/82, SaO 2-98% on room air. B. A client presents with shortness of breath and chest pain, 1 hr. post hemodialysis. States, I get chest pain sometimes, but this time it seems different. Diaphoretic. P-147, R-40, BP 92/71, SaO 2-90% on room air. C. A client with pain/edema to left great toe. Denies recent injury. Limited range of motion. Difficulty ambulating. T-98.9, P-79, R-22, BP-147/62, SaO 2-99% on room air. D. A client with sudden onset of nausea & vomiting 6 hrs. prior to arrival. No history of diabetes. Denies pain or hematemesis. Had lunch outside of home with family today where she ate baked chicken. T-99.7, P-121, R-22, B- 159/86, SaO 2-98% on room air. Emergency Department Triage Review-Hurst Review Services 8

9 8. A. A client, ambulatory to triage after being involved in a 1 car motor vehicle crash. Car vs. light-pole. Refused ambulance care at the scene. Occurred approximately 2 hours prior to arrival. Speed of impact 40 MPH. Unrestrained driver, struck head on windshield. Reports severe neck pain and tingling to toes. P-109, R-18, BP-172/104, SaO 2-99% on room air. B. A client 1-week post TURP. Reports urinary retention x 30 minutes. Passed clots earlier today. States is in moderate pain. Pain # 4 on 1-10 scale P-104, R- 20, BP-159/93. SaO 2-96% on room air. C. 3 y/o toddler with rash x 1 week. Afebrile with temp of 98.9 rectal. R-28, SaO 2-100% on room air. D. A client with vertigo and blurred vision x 3 days. Denies headache or any other pain. Denies injury. Has had family problems at home. T-98.5, P-101, R-18, BP-145/94, SaO 2-99% on room air. Emergency Department Triage Review-Hurst Review Services 9

10 9. A. A client reports left shoulder pain. Onset 1 day ago after moving heavy furniture. Constant in nature. T-98.4, P-77, R-20, BP-148/62, SaO 2-100% on room air. B. A client with rectal bleeding x 4 hours. Color pale. + shortness of breath on exertion. Skin cool/clammy. States bowel movement was dark and tarry. T-96, P-141, R-26, BP 97/49, SaO 2-95% room air. C. A client reports left knee pain. + Dorsalis pedal pulse. Full range of motion. Negative for paresthesias. Was wrapped with ace bandage prior to arrival. T- 98.4, P-99, R-20, BP-131/87, SaO 2-99%. D. A client reports severe lower abd. cramping and irregular menses with heavy blood-flow x 4 months. T-97.4, P-96, R-22, BP-115/70, SaO 2-100% on room air. Emergency Department Triage Review-Hurst Review Services 10

11 10. A. A client fell approximately 5 feet off ladder while painting at home. Landed on lawn with left ankle trapped under buttocks. + edema, no gross deformity. + dorsalis pedal pulse. Moderate pain. T-98.8, P-122, R-26, BP- 141/89, SaO 2-98% on room air. B. A client, restrained driver struck 18-wheeler from behind. + airbag deployment. Approximate speed of impact 45 MPH. Head struck windshield of van. Fully spinal immobilized with c-collar in place. Alert to person only. T-99, P-133, R-28, BP-168/81, SaO 2-93% on 40% O2 facemask. C. A client in per EMS after bumping into neighbor s house with car. Approximate speed of impact 10 MPH. Denies loss of consciousness. Alert and oriented x 3. Denies headache, chest pain, or shortness of breath. Restrained driver. T-97.8, P-72, R-22, BP 128/69, SaO 2-99% on room air. D. A client ambulatory reports right wrist pain. Tripped in flower bed 2 days ago. + right radial pulse. Cap refill < 2 seconds. No obvious deformity.t-97.3, P- 101, R-18, BP-175/101, SaO 2-96% on room air. Emergency Department Triage Review-Hurst Review Services 11

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