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The Emergency Triage
Anusorn Karaker .Registered nurse (RN),MNS.
Rasisalai Hospital , Thailand
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Triage
• “triage” มาจากภาษาฝรงเศสทวา“trier” แปลวา to “sort” or “choose”.
• ระบบในการจำาแนกผปวยตามลาดบความรนแรงของโรค • ซงไดมการรเรมมาตงแตสมยสงครามโลกครงท 1• โดยนายแพทยชาวฝรงเศสชอ Dominique Jean Larrey
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Triage
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“ ” ในสมยนนการจำาแนกไดกระทาโดยการ เดา เปนหลก และเนนคดกรองเพอใหไดรบการรกษาอยางรวดเรวมากกวาความ
แมนยำา
Patient Classification
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Johnson, 1984 : เปนระบบการจดผปวยใหเปนระดบชน และกลมตางๆ ตามลกษณะความเจบปวย โดยมวตถประสงคเพอใชเปนเครองมอจดทาระบบปฏบตการพยาบาลใหเปนมาตรฐาน โดยเฉพาะอยางยงในการประมาณการอตรากาลงบคลากรทางการพยาบาล
Gillies, 1994 : เปนการจดกลมผปวยตามปรมาณและความซบซอนของความตองการในการพยาบาล
Fagerstrom, Eriksson, & Engberg, 1999 : เปนการประเมนความตองการในการดแลเฉพาะบคคลตามชวงเวลา ซงจะแบงตามความตองการในการดแลและกจกรรมการพยาบาล
Faggestrom, Rainio, Rauhala, & Nojonen, 2000 : เปนการจดกลมโดยอาศยการประมาณความตองการการดแลในชวงเวลาใดเวลาหนง ตามการรบรความตองการการดแลผปวย ความรนแรงของความเจบปวย สานกการพยาบาล กระทรวงสาธารณสข (2547) : เปนการจดกลมผปวยในความดแลของพยาบาลในชวงเวลาใดเวลาหนง โดยวตถประสงคเพอการวางแผนการดแล คำานวณและวางแผนอตรากาลงและคำานวณคาใชจายของผปวยแตละกลม และหรอหนวยงาน/องคกร
Patient Classification
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"Who should be seen first ? ""How long can each patient safely
wait ?"Gilboy, Travers, & Wuerz, 1999; Wuerz, Milne,Eitel, Travers, & Gilboy, 2000
Patient Classification
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The American Hospital Association
Emergency Severity Index (ESI)
The American Hospital Association
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Emergency Urgent Nonurgen
t
The 3-level acuity-rating scale•emergent, urgent, and nonurgent•unclear, not uniform and are often hospital dependent and nurse dependent
Emergency Severity Index (ESI)A Triage Tool for EmergencyDepartment Care version 4
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5 ระดบ • ระดบ1 (most urgent) - ระดบ5 (least urgent)
• แบงตามacuity และ resource needs
•ESI concept in 1998
Emergency Severity Index (ESI)A Triage Tool for EmergencyDepartment Care version 4
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Resuscitation Emergent Urgent Less-Urgen
t
Non-Urgen
t
ผปวยวกฤต เจบปวยรนแรง
เจบปวยปานกลาง
เจบปวยเลกนอย
เจบปวยทวไป
Research on the EmergencySeverity Index
•improvements in ED operations•support for research and surveillance•for benchmarking
(Wuerz et al., 2000. ; Travers, Waller, Bowling, Flowers, &Tintinalli, 2002.; Eitel,Travers, Rosenau, Gilboy, & Wuerz, 2003 ; Tanabe, Gimbel, Yarnold, Kyriacou, & Adams, 2004 ; Worster et al., 2004 ; Durani, Breecher, Walmsley, Attia, & Loiselle, 2009)
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The purpose of ED triage
• to prioritize incoming patients and to identify those patients who cannot wait to be seen
• to cope with overcrowding there is a critical need for a valid, reliable triage acuity rating system in order to sort these incoming patients more rapidly and accurately
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• ESI (USA) • Canadian Triage and Acuity Scale (CTAS) • Australasian Triage Scale (ATS) • Manchester Triage Scale (U.K.)
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EmergencySeverity Index Is This a High-Risk Situation?
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EmergencySeverity Index START TRIAGE
30 - 2 -Can do R-P-M
R = Respiration > 30 ครง/นาท..........เปนสแดง
P = Perfusion > 2 วนาท.................จดเปนสแดง
M = Mental status = ทาตามสงได ( Can do)จดเปนสเหลอง
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EmergencySeverity Index
A. dying?B. shouldn't wait?C. many resources?D. vital signs?
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NANDA Nursing Diagnoses
NOC Outcomes and Indicators NIC Intervention Label and select nursing activities
Risk for infection related to immunosuppression secondary to chemotherapy, inadequate primary defenses (central venous catheter), chronic disease (ALL) and developmental level.
0702Immune Status Definition: Natural and acquired appropriately targeted resistance to internal and external antigens.1=severely compromised thru 5= not compromisedAbsolute WBC values WNL(within normal limits)1 2 3 4 5Differential WBC values WNL(within normal limits)1 2 3 4 5Skin integrity1 2 3 4 5Mucosa integrity1 2 3 4 5Body temperature IER( in expected range)1 2 3 4 5Gastrointestinal function1 2 3 4 51 2 3 4 5(NOC, 2008 p.399)
6550 infection protectionDefinition: Prevention and early detection of infection in a patient at riskActivities: Monitor for systemic and localized signs & symptoms of infection (central line site check every 4 hours.) Monitor WBC, and differential results (qod) Follow neutropenic precautions Provide a private room Limit number of visitors Screen all visitors for communicable disease Maintain asepsis Inspect skin and mucous membranes for redness, extreme warmth or drainage (q4 hours) Inspect condition of surgical incision (central line insertion site q 4 hours) Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours) (Drainage @ Central line site) Promote Nutritional intake (1500 kcal per day, Pt likes cereal) Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade) Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM) Monitor for change in energy level/malaise Instruct patient to take anti-infective as prescribed (Bactrim po BID; Nystatin 5cc,swish & swallow, TID) Teach Family about s & symptoms of infection and when to report them to HCP-Teach patient and family how to avoid infections(NIC, 2008)
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Gilboy N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A TriageTool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No.12-0014. Rockville, MD. Agency for Healthcare Research and Quality. November 2011
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European Resuscitation Council Guidelines for Resuscitation
2015Section 1. Executive summary
BCLS & ACLS
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1: Early recognition and call for help2: Early bystander CPR
3: Early defibrillation
4: Early advanced life support and standardised post-resuscitation care
The chain of survival
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1: Early recognition and call for help
The chain of survival
Recognising the cardiac origin of chest pain, and calling the emergency services before a victim collapses, enables the emer- gency medical service to arrive sooner, hopefully before cardiacarrest has occurred, thus leading to better survival
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2: Early bystander CPR
The chain of survival
The immediate initiation of CPR can double or quadruple survival after cardiac arrest.
If able, bystanders with CPR training should give chest compressions together with ventilations.
CPR while awaiting the arrival of professional help.
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3: Early defibrillation
The chain of survival
Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. This can be achieved by public access and onsite AEDs.
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4: Early advanced life support and standardised post-resuscitation care
The chain of survival
Advanced life support with airway management, drugs and correcting causal factors may be needed if initial attempts at resuscitation are un-successful.
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Look , listen and feel for Normal breathing
Alert emergency Service
Send someone to get AED.
Adult BLS sequence
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Adult BLS sequence
Make sure you, the victim and any bystanders are self
Check the Victim for a response
Open the Airway
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Start Chest Compression
Adult BLS sequence
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Combine chest compression with recue breaths
If Untrained or Unable to do Rescue Breaths Continue compression only CPR
Adult BLS sequence
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Switch on the AED and attach the electrode pad
Follow the spoken/visual directions
If Shock is indicated deliver Shock
If no shock is indicated continue CPR
Adult BLS sequence
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Continue CPR
If unresponsive but breathing normallyIf you are certain the victim is breathing normally but still Unresponsive , Place in the recovery position
Adult BLS sequence
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Foreign body airway obstruction (choking)
Suspect Choking Be alert to choking particularly if victim is eating
Encourage to coughInstruct victim to cough
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Foreign body airway obstruction (choking)
Give Back Blows If cough becomes ineffective give up to 5 bag bows
Give abdominal thrusts If back blows are ineffective give up to 5 abdominal thrusts
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Quality During CPR and Treat Reversible Causes
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