Question

NUR 360 Leadership Pre-Work

1. What does triage mean?

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2. Describe what START triage is?

3. Describe the type of patient that fits into each triage color: Green, Yellow, Red, Black.

4. When and where will a nurse need to use triage in their nursing career?

5. How does a nurse working on a medical/surgical unit use triage every day?

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6. Triage the following patients with rational as to why you triaged them in that way:

Victim #1) School aged boy standing in the middle of the room. Pale, shaking, and

crying out loud. No obvious injuries. Doesn’t respond when talked to, but seems alert and aware, and follows your gestures.

Victim #2) Teenage boy in shorts with blistered reddened skin covering both legs. No

evidence of burns above the legs. Alert and talking but has severe pain. No breathing complaints, RR 20. Pulse strong and mildly fast at 110. Good capillary refill. No other injuries.

Victim #3)      Young woman, obviously very pregnant. Complains of shortness of

breath. RR 38, shallow, strained. Skin pale, cool and dry, capillary perfusion > 2 seconds. Conscious, alert, but very agitated. Attempts to answer but has trouble understanding.

Victim #4)      Disheveled adult male, poorly groomed. Wandering around without

purpose, mumbling. Some scratches and abrasions, but no obvious injury. No breathing difficulties. He tells you his name and where he lives, but speech is bizarre. He thinks terrorists are nearby and will shoot him if he leaves. He admits having a psychiatric history.

Victim #5)      Elderly male in a wheelchair. Complains of severe chest pain, radiating to

jaw, with nausea and light-headedness. Alert. RR mildly rapid at 28. Sweaty and pale. Pulse weak, 120. No signs of injury.

Victim #6)      Teen age girl trapped under an overturned piece of furniture. Only

obvious injuries are scrapes, bruises, and a “goose egg” on her forehead. RR 24, pulse 120 and strong, good capillary perfusion. Dazed and confused, unable to help free herself or answer questions, speech garbled.

Victim #7) Middle aged male. Unconscious. Large areas of red blistered burns on

arms, chest, and face, with singed hair on face and head. Horrible burnt flesh smell. Respiration is shallow, irregular and very slow at 4-5/min.

Victim #8)      Healthy appearing senior female on floor with severe leg pain and light-

headedness. Alert and able to answer questions. No respiratory complaints, RR 24. Pulse strong and mildly rapid at 120. Leg has deformity and open wound with bone sticking out. Some ongoing bleeding.

Victim #9) Youngish woman, face down. Large bloody wound on the back of her head,

with visible blood leaking through clothes in many spots. When you roll her over, she is limp and completely unresponsive. When you open her eyes, one pupil is large and fixed. Breathing is slow and irregular at 14, pulse is 60.

Victim #10)   Infant girl about a year old, found under victim #9. Crying loudly, moving

arms and legs, has blood on her, but with close examination, no evidence of injury. No breathing distress, RR 28. Squirming too much to find a pulse, but good capillary refill.

Victim #11)   Preschool aged girl, sitting near victims 9 and 10. Crying and holding her

arm which is obviously deformed. Several small cuts. Able to tell you her arm hurts and wants to know where her mother and sister are. RR 24, pulse 100. No other obvious injury.

Victim #12) Obese late middle-aged male on floor, confused and mumbling. Responds

somewhat to shaking, but not making sense. No obvious trauma. Skin is pale and sweaty and has tremors. RR 30. Pulse 140 but strong. A Med Alert tag on his neck says he has diabetes.

Answer 1

1.When there is a mass disaster affecting a large number of people in a limited time frame and the victims who are in need of immediate medical care depending upon their survival rate the patients are categorized in to priority. This system can help to save a large number of victim with minimal resources and prevention of wastage.

2.START stands for Simple Triage And Rapid Treatment is a method used by a firs aider or a first responder to segregate the patient on the basis of severity in the injury.They separate the patient into four different levels like minor cases, delayed cases,immediate medical care victims and the dead

3.Green :Here the patient are mobile,conscious ,alert and oriented,can manage self to an extent with minimal help  ,wounded minorly (wounds,abrasion, superficial burns,minor cuts )

Yellow:These patients need medical help in a particular time frame from landing up into complications (cuts,fractures,dislocation,bleeding from soft tissues,musculoskeletal problems )

Red:These patients needs immediate attention to safe guard their life .If not treated immediately the life can be lost (cardiac arrest, tachypnea about 30bpm,severe hypotension ,bradypnea,unconscious, does not respond to hard painful stimuli,severe head and chest injury)

Black :This patients are dead and are given the last priority after caring all alive patients.

4.The nurse has to use a triage in the following

• Mass disaster (earthquake, flood,biological disaster, bomb blast,tornado,volcano eruptions ,etc.,)
• Emergency department :isolating the group of patients when received at one time
• Multiple patients in ward showing severe signs and symptoms due to medication error,lack of oxygen supply,lack of resources etc.,