Emergency Nursing: 5-Tier Triage Protocols

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

• ISBN13: 9781582553719
• ISBN10: 1582553718
• Edition: 1st
• Format: Spiral Bound
• Copyright: 2005-10-04
• Publisher: LWW

Summary

This quick-reference handbook presents complaint-based triage protocols for assessing patients face to face in emergency and urgent care settings and assigning acuity levels within the 5-tier triage acuity system. The 5-tier triage acuity system is endorsed by the Emergency Nurses Association and the American College of Emergency Physicians and is rapidly becoming the international standard for emergency care clinical units. Organized alphabetically, the book covers 120 emergent and urgent complaints in all age groups, including environmental exposures and psychiatric presentations. Differential diagnosis charts are included to aid in rapid triage decisions. Nursing pearls are integrated throughout the book.

Table of Contents

Protocols
Abdominal Pain, Adult	1	(2)
Abdominal Pain, Child	3	(2)
Alcohol and Drug Use, Abuse, and Dependence	5	(2)
Allergic Reaction	7	(2)
Altered Mental Status	9	(2)
Ankle Pain and Swelling	11	(2)
Anxiety	13	(2)
Asthma	15	(2)
Back Pain	17	(2)
Bee Sting	19	(2)
Bites, Animal and Human	21	(2)
Bites, Insect and Tick	23	(2)
Bites, Marine Animal	25	(2)
Bites, Snake	27	(2)
Body Art Complications	29	(6)
Breast Problems	35	(2)
Breathing Problems	37	(2)
Burns	39	(2)
Chest Pain	41	(2)
Cold Exposure, Hypothermia/Frostbite	43	(2)
Cold Symptoms	45	(2)
Confusion	47	(2)
Contusion	49	(2)
Cough	51	(2)
Crying Baby	53	(2)
Depression	55	(2)
Diabetic Problems	57	(2)
Diarrhea, Adult	59	(2)
Diarrhea, Pediatric	61	(2)
Ear Problems	63	(2)
Electric Shock/Lightning Injury	65	(2)
Extremity Injury	67	(2)
Eye Injury or Problems	69	(2)
Feeding Tube Problems	71	(2)
Fever	73	(2)
Finger and Toe Problems	75	(2)
Foreign Body, Ear	77	(2)
Foreign Body, Ingested	79	(2)
Foreign Body, Inhaled	81	(2)
Foreign Body, Rectum or Vagina	83	(2)
Foreign Body, Skin	85	(2)
Genital Problems, Male	87	(2)
Headache	89	(2)
Head Injury	91	(2)
Heart Rate, Rapid	93	(2)
Heart Rate, Slow	95	(2)
Heat Exposure	97	(2)
Hip Pain and Swelling	99	(2)
Hives	101	(2)
Hypertension	103	(2)
Itching Without a Rash	105	(2)
Jaundice	107	(2)
Jaundice, Newborn	109	(2)
Knee Pain and Swelling	111	(2)
Laceration	113	(2)
Lightheadedness/Fainting	115	(2)
Menstrual Problems	117	(2)
Motor Vehicle Accident	119	(2)
Mouth Problems	121	(2)
Neck Pain	123	(2)
Nosebleed	125	(2)
Poisoning, Exposure or Ingestion	127	(2)
Pregnancy, Abdominal Pain	129	(2)
Pregnancy, Back Pain	131	(2)
Pregnancy, Vaginal Bleeding	133	(2)
Pregnancy, Vaginal Discharge	135	(2)
Pregnancy, Vomiting	137	(2)
Puncture Wound	139	(2)
Rash, Adult and Pediatric	141	(2)
Rectal Problems	143	(2)
Seizure	145	(2)
Seizure, Pediatric Febrile	147	(2)
Sexual Assault	149	(2)
Shoulder Pain	151	(2)
Sinus Pain and Congestion	153	(2)
Sore Throat	155	(2)
Suicidal Behavior	157	(2)
Sunburn	159	(2)
Toothache/Tooth Injury	161	(2)
Urinary Catheter Problems	163	(2)
Urination Problems	165	(2)
Vaginal Bleeding, Abnormal	167	(2)
Vomiting	169	(2)
Weakness	171	(2)
Wound Infection	173	(2)
Wrist Pain and Swelling	175	(2)
Bibliography	177	(78)
Appendices
A: The PQRSTT Mnemonic Assessment Guide	179	(1)
B: Pediatric Vital Signs: Normal Ranges	180	(1)
C: Ibuprofen Dosage Chart	181	(1)
D: Acetaminophen Dosage Chart	182	(1)
E: Temperature Conversion Chart	183	(2)
F: Weight Conversion Chart	185	(2)
G: Differential Diagnosis of Abdominal Pain	187	(3)
H: Differential Diagnosis of Chest Pain	190	(3)
I: Headache: Common Characteristics	193	(2)
J: MVA Triage Questions	195	(2)
K: Mechanisms of Injury From Trauma: Adult	197	(2)
L: Mechanisms of Injury: School Age and Adolescent	199	(2)
M: Mechanisms of Injury: Toddler and Preschooler	201	(2)
N: Mechanisms of Injury: Infant	203	(2)
O: Drugs of Abuse	205	(6)
P: Poisonings	211	(5)
Q: Biological Agents/Chemical Agents	216	(20)
R: Communicable Diseases, Colds versus Flu, and Sexually Transmitted Diseases	236	(9)
S: Triage Skills Assessment	245	(2)
T: Training Exercises	247	(8)
Index	255