Presentation on theme: "Illinois EMSC1 Assessment and Triage Objectives Upon completion of this lecture, you will be better able to: Discuss the importance of performing a systemic,"— Presentation transcript:
Illinois EMSC1 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 EMSC3 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 EMSC4 INITIAL ASSESSMENT Scene safety assessment “Across–the-room assessment” Brief physical assessment Brief health history
Illinois EMSC5 “ACROSS-THE-ROOM ASSESSMENT” General appearance Airway status Work of breathing Circulatory status Disability (neurological) status
Illinois EMSC6 SCENE SAFETY ASSESSMENT SELF People Environment
Illinois EMSC9 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 EMSC10 BRIEF HEALTH HISTORY SAMPLE SYMPTOMS ALLERGIES MEDICATIONS PAST HISTORY LAST MEAL EVENTS LEADING TO THE ILLNESS OR INJURY
Illinois EMSC11 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 EMSC12 TRIAGE AND TRANSPORT Dependent upon the school nurse’s assessment and interventions Dependent on the IEMP and school emergency plan
Illinois EMSC14 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 EMSC16 EMERGENT CONDITION IS LIFE-THREATENING CARE MUST BE INITIATED IMMEDIATELY
Illinois EMSC17 EMERGENT Example – Gun Shot Wound to the Chest
Illinois EMSC18 URGENT Condition is severe but not life-threatening. It requires medical intervention within two hours but not immediate care.
Illinois EMSC19 URGENT Wrist fracture without neurovascular compromise Dog bite to the ear
Illinois EMSC20 NON-URGENT Condition is non-acute or minor Care can be delayed for hours
Illinois EMSC21 NON-URGENT Example – Minor cut to the lower lip
Illinois EMSC22 TRIAGE PROCESS Initial assessment Triage decision Plan of care Intervention Evaluation Outcome/disposition
Illinois EMSC23 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 EMSC24 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 EMSC25 EVALUATION AND FOLLOW-UP School health record Hospital/primary care provider Prehospital personnel
Illinois EMSC26 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 EMSC27 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.