NURS445: CRITICAL CARE

NURSING
ASSESSMENT AND TRIAGE
PRINCIPLES OF EMERGENCY CARE
 A principle is a law or rule that has to be, or
usually is to be followed, or can be desirably
followed, or is an inevitable consequence of
something, such as the laws observed in nature or
the way that a system is constructed. The
principles of such a system are understood by its
users as the essential characteristics of the system,
or reflecting system's designed purpose, and the
effective operation or use of which would be
impossible if any one of the principles was to be
ignored
PRINCIPLES OF EMERGENCY CARE 2
Immediate assessment and management of
the patient
Airway
Breathing
Circulation
Disability
Environment and exposure
Fits
Glucose
PRINCIPLES OF EMERGENCY CARE3
History
Immediate analgesia and investigations
PRINCIPLES OF TRIAGE
Triage is a continuous process and must be
carried out at regular intervals, taking into
account the patient’s condition
Where there is no lack of resources
(personnel, materials, medicines, transport
vehicles, etc.) all injured persons should
receive optimal care.
In situations where resources are lacking, it
may be necessary to withdraw therapy from
severely injured person
PRINCIPLES OF TRIAGE2
Injured persons should be categories base
on the severity and critical nature of there
injuries
Accuracy of triage decisions could affect
casualty outcomes and the overall success of
the medical response to a disaster
The triaging nurse must possess thorough
knowledge , training and clinical experience
with the types of injuries anticipated for any
specific disaster
PRINCIPLES OF TRIAGE3
Consider all factors when making triage
decisions
Stringent and accurate documentation
GOALS/PRIORITIES OF EMERGENCY CARE
To preserve life
To prevent deterioration before more
definitive treatment can be given
Stabilize the patients
Minimize pain
Uncover the medical condition
GOALS/PRIORITIES OF TRIAGE
Early patient assessment
Priority rating
Assignment to correct area of care and
infection control
Control of patient flow
Initiation of diagnostic measures
Initiation of emergency care
Patient education
EMERGENCY CARE FRAMEWORKS:
COMPONENTS OF LIFE
Communication
 Consciousness
 Human behavior
 Human senses
Airway, Breathing, Circulation
Mobility
Personal
Eating, drinking, elimination
Environmental safety, health, social wellbeing
EMERGENCY CARE FRAMEWORKS: TRAUMA
CARE FRAMEWORKS
Primary Assessment:
 Airway
 Breathing
 Circulation
 Disability
Secondary Assessment:
 Exposing the injury/environmental control
 Full set of vital signs/Five interventions
 Give comfort measures
 Head to toe assessment
 Inspect the back
EMERGENCY CARE FRAMEWORKS2:
MANCHESTER TRIAGE SYSTEM
Immediate Resuscitation
Immediate treatment to preserve life
No delay
Met by emergency team on arrival
Very urgent
Seriously ill or injured
Life not in immediate danger
To be seen in ten (10) minutes
EMERGENCY CARE FRAMEWORKS3:
MANCHESTER TRIAGE SYSTEM
Urgent
Serious problems
Condition stable
To be seen in sixty (60) minutes
Standard
Standard ER cases
No immediate danger or distress
Seen in two (2) hours
EMERGENCY CARE FRAMEWORKS4:
MANCHESTER TRIAGE SYSTEM
Non-urgent
Not true emergencies
Seen in four (4) hours
EMERGENCY CARE FRAMEWORKS: CTAS
Level 1 Resuscitative
Level 2 Emergent
Level 3 Urgent
Level 4 Less urgent
Level 5 Non-urgent
EMERGENCY ASSESSMENT
Rapid systematic approach
Usually, the most dramatic injury is not the
most serious
The primary and secondary surveys provide
the emergency nurse with a methodical
approach to help identify and prioritize
patient needs.
EMERGENCY ASSESSMENT2
Across-the-Room Assessment:
First contact with the ill or injured patient.
Quickly observe the patient’s general
appearance, airway status, work of
breathing, circulatory status, and disability
(neurologic status)
The entire assessment should take less than
a minute.
EMERGENCY ASSESSMENT3
Scene Safety Assessment
Substances: blood or other body fluids,
noxious fumes, toxic chemicals
Situational dangers: an armed perpetrator,
hostages, weapons
Environmental dangers: an unstable
structure, fire, electrical hazards
EMERGENCY ASSESSMENT4
 Brief Physical Assessment
 Supplements your across-the-room assessment
 Completed in no more than a few minutes
 Process is divided into an initial assessment
and detailed assessment
 The goal of the initial assessment is to identify
and treat life-threatening emergencies
 The detailed assessment identifies additional
problems
EMERGENCY ASSESSMENT5
During the assessment process, provide
interventions as necessary to maintain:
 airway
 Breathing
 Circulation
Brief History
EMERGENCY ASSESSMENT6
Initial/Primary Assessment:
A – Airway
B – Breathing
C – Circulation
D – Disability
 AVPU Scale
EMERGENCY ASSESSMENT7
Secondary Assessment: brief, thorough,
systematic assessment designed to identify all
injuries. The steps include :
 Expose/environmental control
 Full set of vital signs
 Five interventions
CPLUG
 Facilitate family presence
 Give comfort measures
 Head to assessment
FIVE INTERVENTIONS
 Place a pulse oximeter in an area with sufficient
blood flow to give an accurate reading.
 Place monitors for real-time heart evaluation.
 Insert an indwelling urinary catheter to monitor
output levels.
 Insert a nasogastric tube and actually look at the
aspirate for frank bleeding before placing it to low
suction.
 Initial labs should be drawn.
TRIAGE: CATEGORIES
Level 1 Resuscitative
Level 2 Emergent
Level 3 Urgent
Level 4 Less urgent
Level 5 Non-urgent
TRIAGE2: DECISIONS
Does the Patient Require Immediate Life-
Saving Intervention?
Should the Patient Wait?
Resource Needs
The Patient's Vital Signs