Management of Care Q 30
Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority?
A. A patient with low-grade fever, headache, and myalgias for the past 72 hours.
B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.
Correct Answer: C. A patient with abdominal and chest pain following a large, spicy meal.
Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention.
Option A: The patient with fever, headache, and muscle aches (classic flu symptoms) should be classified as non-urgent. If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress? The high-risk patient is one who could easily deteriorate, one who could have a threat to life, limb, or organ.
Option B: The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. Once the level 1 and level 2 questions are ruled as negative, the nurse needs to ask how many different resources are needed for the physician to provide adequate care and allow the physician to reach a disposition decision. That decision means discharge, admit to the observation unit or the hospital floor.
Option D: The child’s chin laceration may need to be sutured but is also non-urgent. Differentiating between levels 3,4, and 5 are determined by how many hospital resources the patient will most likely need. If the patient requires two or more hospital resources, the patient is triaged as a level 3. If the patient needs one hospital resource, the patient would be labeled a 4. If the patient does not need any hospital resources, the patient would be labeled a 5.