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Illinois EMSC 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 3
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
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 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 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 18
URGENT
• Condition is severe but not life-threatening. It requires medical intervention within two hours but not immediate care.
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.