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TRIAGE NURSING SECRETS
Triage Nursing Secrets
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By
Polly Zimmermann, RN, MS, MBA, CEN, Associate Professor, Department of Nursing, Harry S. Truman College, Chicago, IL
Robert Herr, MD, MBA, FACEP, CPE, CMCE, Medical Director, PacifiCare of Washington, Attending Emergency Physician, Northwest Emergency Physicians/Team Health, St. Joseph Hospital, Tacoma, WA

Included in series
Secrets,

Description
Part of the Nursing Secrets Series – and written in a question & answer format, Triage Nursing Secrets begins with an overview of triage nursing and moves to a significant section on symptoms and a final section on issues and competencies. This practical resource is a collection of pearls of wisdom and tricks of the trade to aid effective nurse triage decisions. Content includes guiding principles, objective criteria, mnemonics/memory aids, discriminators, determinants from standardized triage systems and differences between the typical presentation of men vs. women in various conditions including stroke, chest pain, and domestic violence.

Contents


I. Overview

1. Triage Essence and Process
2. Triage Systems and Acuities
3. History Secrets
4. Physical Assessment
5. Vital Signs
6. Pain Assessment and Management
7. Triage Diagnostics
8. Protocol Samples
9. Decision-Making and Prioritization Principles
10. Documentation Issues



II. Special Considerations

11. Pediatrics
12. Using A Color-Coded System to Estimate Weight at Triage
13. Geriatric Considerations
14. Gender-Related Considerations
15. Cultural Competencies in Triage
16. Heavy Users (?Frequent Flyers?)



III. Symptoms

17. Rashes
18. Fever
19. Headache
20. Closed Head Injury
21. Dental Pain/Tooth Avulsion
22. Triage and Differential Diagnosis of the Patient with Ear Pain: A Basic Primer
23. Stiff or Sore Neck
24. Sore Throat
25. Vision Changes
26. Shortness of Breath
27. Chest Pain Triage
28. Cough



IV. Abdominal Complaints

29. Nausea and Vomiting
30. Diarrhea and Dehydration
31. Peritonitis
32. Upper Abdominal Presentations
33. Lower Abdominal Pain
34. Gynecological-Related Abdominal Pain
35. Triage and Assessment of Male Genital Pain
36. Pregnancy Considerations
37. Dysuria



V. Orthopedics

38. Low Back Pain
39. Extremity Trauma



VI. Wounds

40. Lacerations and Puncture Wounds
41. Foreign Bodies
42. Piercings (Self-Inflicted)
43. Burns
44. Amputations
45. Minor Motor Vehicle Crashes



VII. Balance Alterations

46. Falls in the Elderly
47. Dizziness, Vertigo, and Weakness
48. Syncope



VIII. Environmental

49. Bites and Stings
50. Near Drowning
51. Environmental Thermo-Emergencies



IX. Psychiatric

52. Triage of the Psychiatric Patient
53. Depression and Suicide
54. Drug Overdoses/Ingestion/Poisoning (Accidental)
55. Differentiating Dementia from Delirium
56. Domestic Violence
57. Bullying
58. Child Abuse
59. Elder Abuse
60. Sexual Assault
61. Alcohol Use and Abuse



X. Disaster and Terrorism Issues

62. Weapons of Mass Destruction/Mass Casualty Incident Triage



XI. Regulatory Issues

63. Health Insurance Portability and Accountability Act (HIPAA)



XII. System Issues

64. Fast Track
65. Phone Triage
66. Prehospital/Emergency Medical (EMS) Triage
67. Trauma Systems and Triage
68. Occupational Health Considerations
69. Violence issues
70. Waiting Room
71. Language and Interpretation Issues
72. Ethics in Triage: One Ethicist Speaks
73. Customer Service/Patient Satisfaction



XIII. Triage Personnel Issues

74. Personnel Qualifications
75. Education and Training for Triage Nurses
76. Taking Care of Yourself and Your Staff
77. PDA Use



XIV. International Standardized 5-Level Triage Systems

78. ENA/ACEP Five-Level Triage Work Group
79. The Emergency Severity Index (ESI) Triage Scale
80. Manchester Triage Scale (MTS)
81. Australian Triage Scale (ATS): A 5-Tier Triage Emergency Scale
82. Canada Triage and Acuity Scale
83. Process of Changing an ED from a 3-Level to a 5-Level System



XV. Samples and Examples

84. Effective Test Questions for Measuring Triage Competency

Bibliographic details
Paperback, 752 pages, publication date: AUG-2005
ISBN-13: 978-0-323-03122-6
ISBN-10: 0-323-03122-6
Imprint: MOSBY


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Last update: 10 Sep 2009
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