Forget me not: What you must always remember in Triage Nursing
Lydia is scheduled for a return demonstration on Triage nursing the following day. Last week they were assigned to research all about triage and tomorrow will be their judgment day. However, she still has a little trouble trying to grasp the concept. What are some of the things should she always remember in Triage Nursing?
- The primary role of a triage nurse is to make a first assessment on any incoming patients to the emergency room.
Triage nurses must be efficient when it comes to prioritizing since it is their job to make quick decisions about the priority of admission as a means of determining the order in which patients will receive treatment. Always prioritize injuries in accordance with need.
- Time is precious
The assessment of a patient’s mental and physical conditions that you perform on the job will need to be done rapidly and appropriately, as time management is one of the most important aspects of working as a triage nurse.
In a short span of time, triage nurses should be able to identify the core medical issue affecting the patient, write down any relevant medical history, identify whether the patient suffers from any allergies or is currently taking medications and measure a number of metrics, including weight, height, blood pressure, heart rate and body temperature.
- Priority levels include low priority, high priority, very high priority and highest priority
When sorting patients, the priority level that a patient falls into all depends on where their injury has been sustained with any injury to the face, chest, neck or cardiovascular areas classified as highest priority. It’s up to a triage nurse to determine this.
- Triage must be performed by a Registered Nurse
Triage is an independent nursing role and vital to patient safety and the efficient delivery of emergency care. Clinical decisions made by triage nurses require multifaceted cognitive process and the Triage Nurse must establish the capacity for critical thinking in environments where available data is limited, partial or unclear.
- Triage nurses must be competent
Registered nurses performing triage must be suitably trained and have demonstrated competency in triage. General nursing education does not adequately prepare the emergency nurse for the complexities of the triage nurse role.
Emergency nurses should complete a standardized triage education course that includes a didactic component and a clinical orientation with a preceptor prior to being assigned triage duties. Staff being trained to undertake triage must be adequately supervised by one who has demonstrated competency in triage.
- Appropriate documentation
Documentation of the patient’s admission (including triage notes) should make reference to the following:
- Date and time of assessment
- Name of attending triage nurse
- Presenting complaint
- Relevant history
- Relevant assessment findings
- Allocated triage category
- If re-triage is necessary the re-triaged ATS along with time &reason for this.
- Assessment and any diagnostic, first aid or other treatment measure provided
- Discharge plan if the patient is discharged from triage or emergency
Sources:
- http://www.nursingschoolhub.com/what-is-triage-nursing/
- http://www.health.wa.gov.au/circularsnew/attachments/580.pdf
- https://www.ena.org/SiteCollectionDocuments/Position%20Statements/TriageQualifications.pdf
- http://www.cena.org.au/wp-content/uploads/2014/10/CENA_Position_Statement_Triage_Nurse.pdf
Liane Clores, RN MAN
Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.
