FIVE-TIER TRIAGE MODELLECTURER:Y.SURAHAYA MOHD YUSOFBSc(Hons) Nursing Practice Development New Castle UK.

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TRIAGE

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Triage Level I Resuscitation•Condition requiring immediate nursing and

physician assessment. Any delay in treatment is potentially life or limb threatening.

•Condition includes:- Airway compromise.- Cardiac arrest.- Severe shock cervical injury.- Multisystem trauma.- LOC- Eclampsia.

Triage level II- emergent• Require nursing assessment and physician assessment within 15 minutes

of arrival.• Conditions includes;- Head injury.- Severe trauma.- Lethargic or agitation.- Conscious over doses.- Severe allergic reaction. - Chemical exposure.- Chest pain.- Back pain- GI bleed with unstable signs.- Stroke- Severe asthma.- Abdominal pain in patients older than age 50. vomiting & diarrhoea with

dehydration.- Fever in infants less than 3 month

Triage II- Ac. Psychotic- Severe headache.- Any pain greater then 7 on a scale of 10- Any sexual assault- Any neonate age 7 day/ younger

Triage level III-Urgent

•Requiring nursing and physician assessment within 30 minute of arrival.

•Condition;- Alert head injury with vomiting.- Mild to moderate asthma.- Moderate trauma- Abuse and neglect- GI bleed with stable vital signs- History of seizure alert on arrival.

Triage level IV- less urgent

•Requiring nursing and physician assessment within one hour( within 1h)

•Condition include:- Alert head injury without vomiting.- Minor trauma- Vomiting and diarrhoea in patient older

without evidence of dehydration.- Minor allergic reaction and chronic back

pain.

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Triage level V- Non Urgent

•Requiring nursing and physician assessment within 2 hours.

•Conditions include:• Minor trauma not acute.•Sore throat.

Reassessment of intervention is important to give:•Client feel that they will not be forgotten

if have a place and staff.•Supporting or caring give them comfort.

Triage System

•Start from lobby at main entrance of A&E department, where the triage nurse can see and observe client and family.

•Give a chance to see professional staff.•The family also feel that they can easily

get any information regarding their family.

Triage History

•The nurse need to analyse client complain.

•Which is the symptom can get through PQRST

•P: Provokes- What provokes the symptom? ( make a better or worse).

•Q: Quality.- What does it feel like? Patient own description word

Triage history• S: severe:

- rate it on scale 1-10• T: Time.

- How long have you had this?- Has it ever happened before?

• T: treatment.- treatment prior to arrival( including home remedies).- what has worked before?

references

•Trauma centre. UIA ( University Islam Antarabangsa).

•Emergency and disaster nursing. Ampang Putri specialist hospital.