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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

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ASSESSMENT AND TRIAGE

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Considerations in Initial Assessment

• History and physical assessment can be simultaneous

• NOTE: The assessment process is stopped to initiate life-saving measures (CPR)

• Cultural and other factors may affect the assessment process

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INITIAL ASSESSMENT

• Scene safety assessment

• “Across–the-room assessment”

• Brief physical assessment

• Brief health history

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“ACROSS-THE-ROOM ASSESSMENT”

• General appearance

• Airway status

• Work of breathing

• Circulatory status

• Disability (neurological) status

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SCENE SAFETY ASSESSMENT

• SELF

• People

• Environment

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BRIEF PHYSICAL ASSESSMENT

• Airway• Breathing• Circulation• Disability• Expose/examine• Fahrenheit• Get vital signs• Head-to-toe assessment• Isolate

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BRIEF HEALTH HISTORY

• Chief complaint• Immunizations/isolation• Allergies• Medications• Past health history• Events surrounding the current problem• Diet• Symptoms associated with the current problem

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BRIEF HEALTH HISTORY

SAMPLE• SYMPTOMS• ALLERGIES• MEDICATIONS• PAST HISTORY• LAST MEAL• EVENTS LEADING TO

THE ILLNESS OR INJURY

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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.

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TRIAGE AND TRANSPORT

• Dependent upon the school nurse’s assessment and interventions

• Dependent on the IEMP and school emergency plan

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TRIAGE

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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

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TRIAGE CATEGORIES

• EMERGENT

• URGENT

• NON-URGENT

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EMERGENT

• CONDITION IS LIFE-THREATENING

• CARE MUST BE INITIATED IMMEDIATELY

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EMERGENTExample – Gun Shot Wound to the Chest

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URGENT

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

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URGENT

Wrist fracture without neurovascular compromise

Dog bite to the ear

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NON-URGENT

• Condition is non-acute or minor

• Care can be delayed for hours

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NON-URGENT Example – Minor cut to the lower lip

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TRIAGE PROCESS

• Initial assessment

• Triage decision

• Plan of care

• Intervention

• Evaluation

• Outcome/disposition

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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

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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

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EVALUATION AND FOLLOW-UP

• School health record

• Hospital/primary care provider

• Prehospital personnel

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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

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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.

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ANY QUESTIONS??