Assessment & Triage SNEC Chapter 3 2019 Illinois
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slide1. Assessment & Triage SNEC Chapter 3 2019 Illinois EMSC 1<br>
slide2. Conflict of Interest/Commercial Support Disclosure This educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters. 2019 Illinois EMSC 2<br>
slide3. Lecture Objectives At the end of this lecture, you will be able to:
Discuss the importance of performing a systematic, prioritized assessment.
Describe 4 components of a systematic assessment process.
Compare and contrast the 3 categories of triage.
Apply systematic assessment techniques to make accurate triage decisions in selected case studies.
Discuss the unique issues involved in assessment and triage of students with special needs. 2019 3 Illinois EMSC<br>
slide4. Assessment Your role as a school nurse is critical
You may treat 5%-10% of the total student population
Your actions can make a critical difference between permanent disability and full recovery
Need to assess the student’s condition
Swiftly and accurately
Can’t overlook key physical and historical findings
Systematic, consistent approach is key 2019 4 Illinois EMSC<br>
slide5. Four Components of a Systematic Assessment Scene safety assessment
Across-the-room assessment
Primary assessment
Secondary assessment
Pain Assessment
History
Head to toe/focused physical examination 2019 5 Illinois EMSC<br>
slide6. Additional Actions Once the emergency is over, it’s also important to attend to
Documentation, including data collection
Evaluation and follow-up
Planning and prevention 2019 6 Illinois EMSC<br>
slide7. Three Key Points Use developmentally appropriate language
Gather history information throughout the process
Treat significant problems as you encounter them 2019 7 Illinois EMSC<br>
slide8. Scene Safety Assessment Hazards
Substances
Situational dangers
Environmental dangers 2019 8 Illinois EMSC<br>
slide9. Across-the-Room Assessment Pediatric Assessment Triangle (PAT) Breathing
Visible movement
Work of breathing
(normal/increased) Circulation
Color of skin Appearance
Mental status
Muscle tone
Body position 2019 9 Illinois EMSC<br>
slide10. Appearance Use TICLS mnemonic
to assess:
Tone
Interactiveness
Consolability
Look
Speech
*Compare to student’s baseline status 2019 10 Illinois EMSC<br>
slide11. Breathing Presence or absence of visible chest wall movement
Work of breathing 2019 11 Illinois EMSC<br>
slide12. Circulation Visible skin color
Pallid
Dusky
Mottled
Cyanotic
Flushed 2019 12 Illinois EMSC<br>
slide13. Primary Assessment C-ABCDE Control any obvious external hemorrhage prior to beginning assessment; begin chest compressions if needed
Airway
Position, sounds, obstruction
Breathing
Rate, depth/pattern, symmetry, sounds, work of breathing, odors, injuries
Circulation
Heart rate and quality of pulses, capillary refill time, skin color, temperature, and moisture, bleeding
Disability
Level of consciousness (AVPU); pupillary response
Exposure
Expose as needed to examine
Protect from exposure to the environment 2019 13 Illinois EMSC<br>
slide14. Reprioritizing (C) Circulation If a student has obvious bleeding, apply direct pressure and elevate the injury if applicable
For any bleeding not controlled by direct pressure, consider applying a pressure dressing or tourniquet (if available) and activating EMS
It is important to control any hemorrhage prior to beginning your C-ABCDE assessment
If a student does not have a palpable pulse, begin chest compressions 2019 Illinois EMSC 14<br>
slide15. Spinal Motion Restriction Any possibility of injury to the head or spine, or if the mechanism of injury is unknown
Provide manual
motion restriction
Maintain until EMS
personnel arrive 2019 15 Illinois EMSC<br>
slide16. Airway: Assess for Patency Can the student vocalize?
Is there an obstruction?
Is edema present? 2019 16 Illinois EMSC<br>
slide17. Breathing Respiratory assessment
Rate
Pattern
Bilateral symmetry of chest wall movement
Adventitious sounds
Increased work of breathing
Retractions, nasal flaring
Unusual odors
Chest wall integrity 2019 17 Illinois EMSC<br>
slide18. Circulation Heart rate and quality of pulses
Perfusion
Capillary refill time
Color
Temperature
Moisture
Bleeding
Assess for hemorrhage
Control any
bleeding 2019 18 Illinois EMSC<br>
slide19. Disability Assessment - AVPU Scale 2019 19 Illinois EMSC<br>
slide20. Exposure Remove clothing as needed
Control ambient temperature
Prevent heat loss/provide warming mechanism
Provide covering if clothing removed to maintain body temperature
Watch for signs of bleeding 2019 20 Illinois EMSC<br>
slide21. Secondary Assessment Full Set of Vital Signs
Give Comfort Measures
History
Head to Toe/Focused Physical Examination
Isolate/Inspect 2019 Illinois EMSC 21<br>
slide22. Full Set of Vital Signs Baseline vital signs
Heart rate
Respiratory rate
Blood pressure
Temperature
Be aware of normal pediatric vital sign ranges
Additional assessments
Weight
Blood glucose 2019 22 Illinois EMSC<br>
slide23. Give Comfort Measures/Pain Assessment PQRST Mnemonic:
P – Problem, Provoke, and Palliate
Q – Quality
R – Radiate
S – Severity, Signs, and Symptoms
T – Timing 2019 23 Illinois EMSC<br>
slide24. History Symptoms
Allergies
Medications
Past health history
Last meal
Events that led up to injury 2019 24 Illinois EMSC<br>
slide25. History - CIAMPEDS Chief Complaint
Immunization/isolation
Allergies
Medications
Past health history
Events preceding the problem
Diet/elimination
Symptoms associated with the problem 2019 Illinois EMSC 25<br>
slide26. Head to Toe/Focused Physical Examination Perform a head to toe examination or focused physical examination
Components of assessment include;
Inspection
Auscultation
Palpation
Percussion
Examples include cranial nerve function, extremity range of motion, and abdominal palpation 2019 26 Illinois EMSC<br>
slide27. Triage Principles of triage
Objective process
Prioritize care
Delegate wisely within the scope of practice of the provider
Reassess frequently to determine need to change triage category 2019 27 Illinois EMSC<br>
slide28. Triage Emergent
Student requires immediate medical attention. Condition is acute and has the potential to threaten life, limb, or vision
Urgent
Student requires additional medical intervention within 2 hours. Condition is acute but not severe or life-threatening.
Non-urgent
Student may require referral for routine medical care. Minor or nonacute conditions. 2019 28 Illinois EMSC<br>
slide29. 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 RNs for triage
Reassessment is necessary and essential
Maintain emergency skills/knowledge 2019 Illinois EMSC 29<br>
slide30. Emergent CONDITION IS LIFE-THREATENING
Care must be initiated immediately
Example – Gun shot wound to the chest 2019 Illinois EMSC 30<br>
slide31. Urgent Condition is severe but not life-threatening.
Requires medical intervention within two hours but not immediate care.
Examples:
Wrist fracture without neurovascular compromise
Dog bite to the ear 2019 Illinois EMSC 31<br>
slide32. Non-urgent Condition is non-acute or minor
Care can be delayed for hours
Example: Minor cut to the lip 2019 Illinois EMSC 32<br>
slide33. Ongoing Monitoring and Reassessment Condition can abruptly deteriorate after initially appearing to be non-urgent
Requires frequent reevaluations
Assure ongoing monitoring and observation. Who is qualified to monitor this situation? 2019 Illinois EMSC 33<br>
slide34. Final Disposition Return to class
Observe in the health office
Transport to home, physician’s office or emergency department with a parent or guardian
Transport to the emergency department by EMS 2019 Illinois EMSC 34<br>
slide35. Completing the Process Documentation and data collection
Follow-up
Student’s primary health care provider
EMS/Prehospital care professionals
Emergency department
Parent/guardian 2019 35 Illinois EMSC<br>
slide36. Prevention Establish written guidelines
Designate appropriately
Maintain practice/knowledge requirements
Know your students
IHP’s and emergency plans
Share critical information with other school personnel as appropriate 2019 Illinois EMSC 36<br>
slide37. Students With Special Needs Adjust techniques as needed
Developmental age vs chronological age
Variant baseline values
Focus on the student, not just the specialized equipment
Adjust monitoring as needed 2019 37 Illinois EMSC<br>
slide38. Summary Recognize severe illness or injury among the students in your school
Systematic, consistent assessment schema
Basis for determining the urgency of each student’s condition
Treat students according to acuity
Written triage protocols and policies are important 2019 38 Illinois EMSC<br>
slide39. Any Questions??? 2019 39 Illinois EMSC<br>
slide2. Conflict of Interest/Commercial Support Disclosure This educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters. 2019 Illinois EMSC 2<br>
slide3. Lecture Objectives At the end of this lecture, you will be able to:
Discuss the importance of performing a systematic, prioritized assessment.
Describe 4 components of a systematic assessment process.
Compare and contrast the 3 categories of triage.
Apply systematic assessment techniques to make accurate triage decisions in selected case studies.
Discuss the unique issues involved in assessment and triage of students with special needs. 2019 3 Illinois EMSC<br>
slide4. Assessment Your role as a school nurse is critical
You may treat 5%-10% of the total student population
Your actions can make a critical difference between permanent disability and full recovery
Need to assess the student’s condition
Swiftly and accurately
Can’t overlook key physical and historical findings
Systematic, consistent approach is key 2019 4 Illinois EMSC<br>
slide5. Four Components of a Systematic Assessment Scene safety assessment
Across-the-room assessment
Primary assessment
Secondary assessment
Pain Assessment
History
Head to toe/focused physical examination 2019 5 Illinois EMSC<br>
slide6. Additional Actions Once the emergency is over, it’s also important to attend to
Documentation, including data collection
Evaluation and follow-up
Planning and prevention 2019 6 Illinois EMSC<br>
slide7. Three Key Points Use developmentally appropriate language
Gather history information throughout the process
Treat significant problems as you encounter them 2019 7 Illinois EMSC<br>
slide8. Scene Safety Assessment Hazards
Substances
Situational dangers
Environmental dangers 2019 8 Illinois EMSC<br>
slide9. Across-the-Room Assessment Pediatric Assessment Triangle (PAT) Breathing
Visible movement
Work of breathing
(normal/increased) Circulation
Color of skin Appearance
Mental status
Muscle tone
Body position 2019 9 Illinois EMSC<br>
slide10. Appearance Use TICLS mnemonic
to assess:
Tone
Interactiveness
Consolability
Look
Speech
*Compare to student’s baseline status 2019 10 Illinois EMSC<br>
slide11. Breathing Presence or absence of visible chest wall movement
Work of breathing 2019 11 Illinois EMSC<br>
slide12. Circulation Visible skin color
Pallid
Dusky
Mottled
Cyanotic
Flushed 2019 12 Illinois EMSC<br>
slide13. Primary Assessment C-ABCDE Control any obvious external hemorrhage prior to beginning assessment; begin chest compressions if needed
Airway
Position, sounds, obstruction
Breathing
Rate, depth/pattern, symmetry, sounds, work of breathing, odors, injuries
Circulation
Heart rate and quality of pulses, capillary refill time, skin color, temperature, and moisture, bleeding
Disability
Level of consciousness (AVPU); pupillary response
Exposure
Expose as needed to examine
Protect from exposure to the environment 2019 13 Illinois EMSC<br>
slide14. Reprioritizing (C) Circulation If a student has obvious bleeding, apply direct pressure and elevate the injury if applicable
For any bleeding not controlled by direct pressure, consider applying a pressure dressing or tourniquet (if available) and activating EMS
It is important to control any hemorrhage prior to beginning your C-ABCDE assessment
If a student does not have a palpable pulse, begin chest compressions 2019 Illinois EMSC 14<br>
slide15. Spinal Motion Restriction Any possibility of injury to the head or spine, or if the mechanism of injury is unknown
Provide manual
motion restriction
Maintain until EMS
personnel arrive 2019 15 Illinois EMSC<br>
slide16. Airway: Assess for Patency Can the student vocalize?
Is there an obstruction?
Is edema present? 2019 16 Illinois EMSC<br>
slide17. Breathing Respiratory assessment
Rate
Pattern
Bilateral symmetry of chest wall movement
Adventitious sounds
Increased work of breathing
Retractions, nasal flaring
Unusual odors
Chest wall integrity 2019 17 Illinois EMSC<br>
slide18. Circulation Heart rate and quality of pulses
Perfusion
Capillary refill time
Color
Temperature
Moisture
Bleeding
Assess for hemorrhage
Control any
bleeding 2019 18 Illinois EMSC<br>
slide19. Disability Assessment - AVPU Scale 2019 19 Illinois EMSC<br>
slide20. Exposure Remove clothing as needed
Control ambient temperature
Prevent heat loss/provide warming mechanism
Provide covering if clothing removed to maintain body temperature
Watch for signs of bleeding 2019 20 Illinois EMSC<br>
slide21. Secondary Assessment Full Set of Vital Signs
Give Comfort Measures
History
Head to Toe/Focused Physical Examination
Isolate/Inspect 2019 Illinois EMSC 21<br>
slide22. Full Set of Vital Signs Baseline vital signs
Heart rate
Respiratory rate
Blood pressure
Temperature
Be aware of normal pediatric vital sign ranges
Additional assessments
Weight
Blood glucose 2019 22 Illinois EMSC<br>
slide23. Give Comfort Measures/Pain Assessment PQRST Mnemonic:
P – Problem, Provoke, and Palliate
Q – Quality
R – Radiate
S – Severity, Signs, and Symptoms
T – Timing 2019 23 Illinois EMSC<br>
slide24. History Symptoms
Allergies
Medications
Past health history
Last meal
Events that led up to injury 2019 24 Illinois EMSC<br>
slide25. History - CIAMPEDS Chief Complaint
Immunization/isolation
Allergies
Medications
Past health history
Events preceding the problem
Diet/elimination
Symptoms associated with the problem 2019 Illinois EMSC 25<br>
slide26. Head to Toe/Focused Physical Examination Perform a head to toe examination or focused physical examination
Components of assessment include;
Inspection
Auscultation
Palpation
Percussion
Examples include cranial nerve function, extremity range of motion, and abdominal palpation 2019 26 Illinois EMSC<br>
slide27. Triage Principles of triage
Objective process
Prioritize care
Delegate wisely within the scope of practice of the provider
Reassess frequently to determine need to change triage category 2019 27 Illinois EMSC<br>
slide28. Triage Emergent
Student requires immediate medical attention. Condition is acute and has the potential to threaten life, limb, or vision
Urgent
Student requires additional medical intervention within 2 hours. Condition is acute but not severe or life-threatening.
Non-urgent
Student may require referral for routine medical care. Minor or nonacute conditions. 2019 28 Illinois EMSC<br>
slide29. 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 RNs for triage
Reassessment is necessary and essential
Maintain emergency skills/knowledge 2019 Illinois EMSC 29<br>
slide30. Emergent CONDITION IS LIFE-THREATENING
Care must be initiated immediately
Example – Gun shot wound to the chest 2019 Illinois EMSC 30<br>
slide31. Urgent Condition is severe but not life-threatening.
Requires medical intervention within two hours but not immediate care.
Examples:
Wrist fracture without neurovascular compromise
Dog bite to the ear 2019 Illinois EMSC 31<br>
slide32. Non-urgent Condition is non-acute or minor
Care can be delayed for hours
Example: Minor cut to the lip 2019 Illinois EMSC 32<br>
slide33. Ongoing Monitoring and Reassessment Condition can abruptly deteriorate after initially appearing to be non-urgent
Requires frequent reevaluations
Assure ongoing monitoring and observation. Who is qualified to monitor this situation? 2019 Illinois EMSC 33<br>
slide34. Final Disposition Return to class
Observe in the health office
Transport to home, physician’s office or emergency department with a parent or guardian
Transport to the emergency department by EMS 2019 Illinois EMSC 34<br>
slide35. Completing the Process Documentation and data collection
Follow-up
Student’s primary health care provider
EMS/Prehospital care professionals
Emergency department
Parent/guardian 2019 35 Illinois EMSC<br>
slide36. Prevention Establish written guidelines
Designate appropriately
Maintain practice/knowledge requirements
Know your students
IHP’s and emergency plans
Share critical information with other school personnel as appropriate 2019 Illinois EMSC 36<br>
slide37. Students With Special Needs Adjust techniques as needed
Developmental age vs chronological age
Variant baseline values
Focus on the student, not just the specialized equipment
Adjust monitoring as needed 2019 37 Illinois EMSC<br>
slide38. Summary Recognize severe illness or injury among the students in your school
Systematic, consistent assessment schema
Basis for determining the urgency of each student’s condition
Treat students according to acuity
Written triage protocols and policies are important 2019 38 Illinois EMSC<br>
slide39. Any Questions??? 2019 39 Illinois EMSC<br>