3-Five-tier Triage Model - Copy
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Transcript of 3-Five-tier Triage Model - Copy
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FIVE-TIER TRIAGE MODELLECTURER:Y.SURAHAYA MOHD YUSOFBSc(Hons) Nursing Practice Development New Castle UK.
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Triage Level I Resuscitation•Condition requiring immediate nursing and
physician assessment. Any delay in treatment is potentially life or limb threatening.
•Condition includes:- Airway compromise.- Cardiac arrest.- Severe shock cervical injury.- Multisystem trauma.- LOC- Eclampsia.
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Triage level II- emergent• Require nursing assessment and physician assessment within 15 minutes
of arrival.• Conditions includes;- Head injury.- Severe trauma.- Lethargic or agitation.- Conscious over doses.- Severe allergic reaction. - Chemical exposure.- Chest pain.- Back pain- GI bleed with unstable signs.- Stroke- Severe asthma.- Abdominal pain in patients older than age 50. vomiting & diarrhoea with
dehydration.- Fever in infants less than 3 month
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Triage II- Ac. Psychotic- Severe headache.- Any pain greater then 7 on a scale of 10- Any sexual assault- Any neonate age 7 day/ younger
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Triage level III-Urgent
•Requiring nursing and physician assessment within 30 minute of arrival.
•Condition;- Alert head injury with vomiting.- Mild to moderate asthma.- Moderate trauma- Abuse and neglect- GI bleed with stable vital signs- History of seizure alert on arrival.
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Triage level IV- less urgent
•Requiring nursing and physician assessment within one hour( within 1h)
•Condition include:- Alert head injury without vomiting.- Minor trauma- Vomiting and diarrhoea in patient older
without evidence of dehydration.- Minor allergic reaction and chronic back
pain.
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Triage level V- Non Urgent
•Requiring nursing and physician assessment within 2 hours.
•Conditions include:• Minor trauma not acute.•Sore throat.
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Reassessment of intervention is important to give:•Client feel that they will not be forgotten
if have a place and staff.•Supporting or caring give them comfort.
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Triage System
•Start from lobby at main entrance of A&E department, where the triage nurse can see and observe client and family.
•Give a chance to see professional staff.•The family also feel that they can easily
get any information regarding their family.
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Triage History
•The nurse need to analyse client complain.
•Which is the symptom can get through PQRST
•P: Provokes- What provokes the symptom? ( make a better or worse).
•Q: Quality.- What does it feel like? Patient own description word
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Triage history• S: severe:
- rate it on scale 1-10• T: Time.
- How long have you had this?- Has it ever happened before?
• T: treatment.- treatment prior to arrival( including home remedies).- what has worked before?
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references
•Trauma centre. UIA ( University Islam Antarabangsa).
•Emergency and disaster nursing. Ampang Putri specialist hospital.