Emergency nursing : 5-tier triage protocols

320 Pages·2020·1.618 MB·English

by  Julie K. Briggs, Valerie G. A. Grossman

Julie K. Briggs
Valerie Aarne Grossman
EMERGENC Y
NURSING
5-Tier

Triage Protocols

S E C O N D E D I T I O N
EMERGENCY
NURSING
5-Tier Triage Protocols
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Julie K. Briggs, BSN, RN, MHA, is a registered nurse with 40 years of expe-
rience in emergency nursing. She has provided nursing leadership in mul-
tiple hospital departments including emergency care, critical care, cardiac
catheterization laboratory, radiology, and ambulatory care. Additional areas
of expertise include disaster response, management and training, telephone
triage training, program development, and consulting. Publications include
Emergency Nursing: 5-Tier Triage Protocols, Telephone Triage Protocols for Nurses,
editions 1–5, Telephone Triage Protocols for Pediatrics, and Triage Protocols for Ag-
ing Adults. In addition, Ms. Briggs has contributed multiple articles and book
chapters in emergency nursing, leadership, and home health. She currently
works at Providence Health Plan in Quality Management in Portland, Oregon.
Valerie Aarne Grossman, MALS, BSN, RN, NE-BC, is a registered nurse
with four decades of heterogeneous nursing experience including bedside
nursing, nursing leadership, and hospital administration. She is a nurse
author and serves with multiple nursing organizations. Her areas of expertise
include emergency nursing, telephone triage, radiology nursing, and nursing
leadership. Ms. Aarne Grossman currently serves as the Vice-Chairperson
for the New York State Board of Nursing (2019–2020) and the Chairperson
(2020–2021). She volunteers for a number of organizations and boards of
directors including the New York State Board of Nursing, the Association for
Radiologic & Imaging Nursing (ARIN), and the Journal of Radiology Nursing.
She is a prolifi c author of numerous books, chapters, and articles. She is a
manuscript reviewer for journals from around the world. She is an award-
winning nurse, most recently was named the ARIN Radiology Nurse of the
Year, and received the American Nurses Association Honorary Nursing Prac-
tice Award. Her advocacy for the bedside nurse drives her passion for pro-
fessional involvement and dedication to providing the profession of nursing
with written tools that can help nurses reach their full potential in providing
patient care.
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S E C O N D E D I T I O N
EMERGENCY
NURSING
5-Tier Triage Protocols
Julie K. Briggs,
BSN, RN, MHA
Valerie Aarne Grossman,
MALS, BSN, RN, NE-BC
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ISBN: 978-0-8261-3788-3
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DOI: 10.1891/9780826137913
19 20 21 22 / 5 4 3 2 1
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Library of Congress Cataloging-in-Publication Data
Names: Briggs, Julie K., author. | Grossman, Valerie G. A., author.
Title: Emergency nursing : 5-tier triage protocols / Julie K. Briggs,
Valerie Aarne Grossman.
Description: Second edition. | New York : Springer Publishing Company,
[2020] | Includes bibliographical references and index.
Identifiers: LCCN 2019029276 (print) | ISBN 9780826137883 (hardcover) |
ISBN 9780826137913 (ebook)
Subjects: MESH: Emergency Nursing | Triage--methods | Emergencies--nursing
| Emergency Service, Hospital | Handbook
Classification: LCC RC86.7 (print) | LCC RC86.7 (ebook) | NLM WY 49 |
DDC 616.02/5--dc23
LC record available at https://lccn.loc.gov/2019029276
LC ebook record available at https://lccn.loc.gov/2019029277
Contact us to receive discount rates on bulk purchases.
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For more information please contact: [email protected]
Julie K. Briggs: https://orcid.org/0000-0001-7731-9819
Valerie Aarne Grossman: https://orcid.org/0000-0002-7648-7113

Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for
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CONTENTS
Preface ix
Acknowledgments xiii
Share: Emergency Nursing: 5-Tier Triage Protocols, Second Edition
Protocols
1. Abdominal Pain, Adult 1
2. Abdominal Pain, Pediatric 3
3. Alcohol and Drug Use, Abuse, Overdose, and Dependence 5
4. Allergic Reaction 7
5. Altered Mental Status 9
6. Ankle Pain and Swelling 11
7. Anxiety 13
8. Asthma 15
9. Back Pain 17
10. Bee Sting 19
11. Bites, Animal and Human 21
12. Bites, Insect and Tick 23
13. Bites, Marine Animal 25
14. Bites, Snake 27
15. Body Art Complications 29
16. Breast Problems 37
17. Breathing Problems 39
18. Burns 43
19. Chest Pain 45
20. Cold Exposure, Hypothermia/Frostbite 47
21. Cold Symptoms 49
22. Confusion 51
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23. Contusion 53 nt
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24. Cough 55 C
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25. Crying Baby 57
26. Depression 59
27. Diabetic Problems 61
28. Diarrhea, Adult 63
29. Diarrhea, Pediatric 65
30. Ear Problems 67
31. Electric Shock/Lightning Injury 69
32. Extremity Injury 71
33. Eye Injury or Problems 73
34. Feeding Tube Problems 75
35. Fever 77
36. Finger and Toe Problems 79
37. Foreign Body, Ear 81
38. Foreign Body, Ingested 83
39. Foreign Body, Inhaled 85
40. Foreign Body, Rectum or Vagina 87
41. Foreign Body, Skin 89
42. Genital Problems, Female 91
43. Genital Problems, Male 93
44. Headache 95
45. Head Injury 97
46. Heart Rate, Rapid 99
47. Heart Rate, Slow 101
48. Heat Exposure 103
49. Hip Pain/Injury 105
50. Hives 107
51. Hypertension 109
52. Itching Without a Rash 111
53. Jaundice 113
54. Jaundice, Newborn 115
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ent 55. Knee Pain and/or Swelling 117
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57. Lightheadedness/Fainting 121
58. Menstrual Problems 123
59. Mouth Problems 125
60. Neck Pain 127
61. Nosebleed 129
62. Poisoning, Exposure or Ingestion 131
63. Pregnancy, Abdominal Pain 133
64. Pregnancy, Back Pain 135
65. Pregnancy, Vaginal Bleeding 137
66. Pregnancy, Vaginal Discharge 139
67. Pregnancy, Vomiting 141
68. Puncture Wound 143
69. Rash, Adult and Pediatric 145
70. Rectal Problems 147
71. Seizure 149
72. Seizure, Pediatric Febrile 151
73. Sexual Assault 153
74. Shoulder Pain 155
75. Sinus Pain and Congestion 157
76. Sore Throat 159
77. Stroke 161
78. Suicidal Behavior 163
79. Sunburn 165
80. Toothache/Tooth Injury 167
81. Traumatic Injury 169
82. Urinary Catheter Problems 171
83. Urination Problems 173
84. Vaginal Bleeding, Abnormal 175
85. Vomiting 177
86. Weakness 179
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87. Wound Infection 181 ntent
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88. Wrist Pain and Swelling 183 | C
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Appendices
A: Triage Program Development 185
B: Key Questions to Ask Triage Nurses 197
C: Triage Pearls 200
D: Triage Training Outline 203
E: Triage Training Exercises 206
F: Triage Assessment Skills Checklist 218
G: Chart Audit Tool 221
H: Triage Log 222
I : Differential Assessment of Abdominal Pain 223
J: Differential Assessment of Chest Pain 226
K: Headache: Common Characteristics 229
L: MVA Triage Questions 231
M: Mechanisms of Injury: Adult 234
N: Mechanisms of Injury: School Age and Adolescent (7–17 years old) 236
O: Mechanisms of Injury: Toddler and Preschooler (1–6 years old) 238
P: Mechanisms of Injury: Infant (birth to 1 year old) 240
Q: Drugs of Abuse 242
R: Poisonings 251
S: Biological Agents/Chemical Agents 257
T: Communicable Diseases, Colds Versus Flu, and Sexually
Transmitted Diseases 286
Bibliography 297
Index 301
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PREFACE
The process of triage occurs in a variety of settings around the world, from the
battlefi eld to the private medical offi ce. Each venue may have different goals
and practices that are dependent on the location of the incident or place of
service, patient care needs, and available medical resources. A triage process
is essential to assist the care provider in prioritizing the needs of those seeking
care, working to minimize or prevent a delay in care to the patient with the
highest acuity risk. Triage methods and sources have evolved over many de-
cades and now address the needs of different practice settings.
The Need for 5-Level Triage Protocols
Today, most healthcare organizations (emergency departments, urgent care
centers, infi rmaries, clinics, etc.) in countries around the world use some type
of triage acuity system to determine how quickly a patient needs to be seen
and who can safely wait until services are available to provide the necessary
care. Over the past 10 to 15 years, many organizations have transitioned to a
5-Tier Acuity System. Some countries have developed their own triage system
that consists of 3 to 5 levels of acuity. Do a quick Internet search and you will
fi nd a wide variety available—some are electronic and some continue to use
pen and paper. In Emergency Nursing: 5-Tier Triage Protocols (Second Edition),
the term “emergency department” is frequently used; however, all providers
of healthcare that use a triage system will benefi t from this valuable resource.
In today’s rapidly changing healthcare environment, an effi cient emergency
department is critical to providing appropriate care at the appropriate time in
the appropriate setting. A 5-level triage system helps to ensure that patients
are not overtriaged, which depletes scarce resources that may be needed for
a patient requiring immediate intervention, or undertriaged, which puts the
patient at risk for deterioration while waiting to be seen.
Emergency Nursing: 5-Tier Triage Protocols will assist the triage nurse to func-
tion in a more consistent, reliable, and safe manner. The fi ve levels are Resusci-
tation, Emergent, Urgent, Semi-urgent, and Nonurgent, and they are based on
patient acuity, severity of symptoms, the degree of risk for deterioration while
waiting, and the need for additional resources. In the protocols, ascending
levels of urgency are indicated by bolder headings and shading.
This protocol manual can help to achieve the following goals:
• Provide consistency in triage decisions among different nurses
• Utilize healthcare resources in the most appropriate manner ace
• Set minimum expectations for triage decisions Pref
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