ESI and triage

Question 1

The first question a nurse would ask, in which a patient would be triaged as a ESI level 1 if the answer is yes, is…

Answer 1

is the patient dying?

a no would move on to the next step in the algorithm

Question 2

ESI level 1 patients usually account for __-__% of ED patients

Answer 2

1 - 3%

Question 3

Name some examples of an ESI level 1 patient

11

Answer 3

Severe respiratory distress
Overdose with respirations <6
Severe bradycardia/tachycardia with hypotension
Traumatic injury with hypotension
Anaphylactic reaction
Hypoglycemia with change in mental status
Chest pain, diaphoretic, with hypotension
Baby that is flaccid
Cardiac arrest
Respiratory arrest
Emergency Bipap

Question 4

The second question that the nurse should ask him/herself when triaging a patient is what?
What are three other questions that support this question?

Answer 4

Can the patient wait?

1. Is the situation high risk?
2. Is the patient confused lethargic, or disoriented?
3. Is the patient in severe pain or distress?

Question 5

ESI level 2 patients make up about __-__% of the ED patient population.

Answer 5

20-30%

Question 6

Name some examples of triage level 2 patients
(24)
I know, I know, it’s a lot
don’t worry, they’re broken down into individual cards later :)

Answer 6

• Chest pain, suspicious of coronary syndrome, with stable vitals
• Healthcare worker with a needlestick
• Signs of a stroke
• R/O ectopic pregnancy
• Fever in the immunocompromised
• Suicidal or homicidal patient
• Change in mental status
• Testicular torsion
• Spontaneous pneumothorax with elevated RR rate
• Seizure
• Patient in severe pain
• Hypertensive crisis
• Peritonsillar abscess
• Inhalation injury with airway compromise
• Hypo/Hyperglycemia
• Sepsis
• Syncope
• Urinary retention
• Sudden change or loss in vision
• Chemical splash to eyes
• Hip / extremity dislocation
• Pelvic /Femur fracture
• Infant > 28 days with a fever
• Accidental/intentional ingestion

Question 7

If the patient isn’t dying and can wait, what is the third question a nurse should ask him or herself about the patient?
What are three possible answers to the question?

Answer 7

How many resources will the patient need?

1. none
2. one
3. many

Question 8

Name some ED services that are considered resources.

10

Answer 8

Labs
EKG
X-ray
CT
MRI
Ultrasound
IV, IM, or nebulized medications 
Specialty consultations 
Simple procedure = 1 resource (lac repair, Foley cath)
Complex procedure = 2 resources (conscious sedation)

Question 9

After coming to the third question (ESI level 3), name a factor that might make a nurse change their decision to a level 2?

Answer 9

Abnormal vital signs.
The presence of abnormal vital signs may not be enough to upgrade, as it is how meaningful to the patients condition they are.

Question 10

What are some examples of ESI level 3 Horizontal patients

9

Answer 10

• abdominal pain
• HA/ Migraine
• Flank pain
• Vaginal bleeding with stable VS
• Painful, swollen lower leg pain with no trauma, R/O DVT
• Fractured hip
• Asthma with mild wheezing
• N/V/D
• Fractured, dislocated wrist

Question 11

What are some examples of ESI level 3 Vertical patients?

6

Answer 11

• Nausea, no vomiting
• Cellulitis
• Low back pain
• Fall that is ambulatory
• MVA that is ambulatory
• Bronchitis

Question 12

Any infant less than 28 days old that presents with a fever in considered ____ until proven otherwise and should be an ESI level __

Answer 12

septic

2

Question 13

Any patient known to be pregnant who presents with edema and BP above 150/100 should be considered as ____ and triaged at a priority __

Answer 13

2

pre-eclamptic

Question 14

If a patient with a head injury presents with neck pain, a blow to the head or chest, and sudden acceleration/deceleration must be considered a C-spine injury until what?
What should be done immediately?

Answer 14

cleared by a physician

C spine precautions should be taken immediatly

Question 15

All patients less than 12 years of age must be ____, included with vital signs.

Answer 15

weighed

Question 16

All patients with an eye injury need what?

Answer 16

visual acuity

Question 17

Priority 2 eye injuries include

3

Answer 17

• sudden pain or loss of vision
• direct blow to the eye with difficulty moving the eye in all directions
• chemicals splashed into the eye

Question 18

Children and adults who have lost a permanent tooth need to be triaged as a priority __

Answer 18

2

there is a narrow window of opportunity for reimplantation

Question 19

Bleeding as a post-op complication from a tosilectomy or a tooth extraction needs to be triaged as a priority __

Answer 19

2

Question 20

Any unstable fracture, deformity, or open fracture should be splinted prior to what?
what are three other things you should do?

Answer 20

going to x-ray

• remember to splint the limb as you find it
• check for pulse and circulation after splinting
• apply ice

Question 21

What should you tell a person seeking medical advise through a telephone call?

Answer 21

It is Inspira policy to instruct patients to either come to the ED or contact their personal physician.

Question 22

What should you tell a person who calls in requesting an ambulance?

Answer 22

instruct them to dial 9-1-1

Question 23

Remove ____ distal to all injuries.

Answer 23

jewelry

Question 24

what are the four triage questions?

Answer 24

• is the patient dying?
• is this a patient who shouldn’t wait?
• how many resources will this patient need?
• what are the patients vital signs?

Question 25

The first question; is the patient dying? If the answer is yes then what? What are two other questions to help you decide? question 1 (3) question 2 (8)

Answer 25

``` ESI 1 1 Does the patient require an -immediate airway -medication -other hemodynamic intervention 2 Does the patient meet any of the following criteria; - already intubated - apneic - pulseless - severe respiratory distress spO2<90% - acute mental status change - unresponsive ```

Question 26

The key difference between ESI level 1 and 2 is what?

Answer 26

immediate physician involvement

Question 27

ESI level __ patients are seriously ill, but the emergency care nurse can initiate care through standing orders without a physician at bedside.

Answer 27

2 | the patient needs rapid interventions but will not deteriorate immediately

Question 28

Name some examples of ESI level 1 patients | 16

Answer 28

- cardiac arrest - respiratory arrest - severe respiratory distress - spO2 <90% - unresponsive trauma - overdose with a respiratory rate <10 - agonal or gasping respirations - severe bradycardia or tachycardia with s/s of hypoperfusion - hypotension with s/s of hypoperfusion - trauma patients who require fluid resusitation - chest pain with weak and dizzyness, hypotensive - anaphylactic reaction - baby that is flacid - unresponsive with odor of alcohol - hypoglycemia with altered mental status

Question 29

after deciding that the patient does not meet the criteria for ESI level 1, what is the question that the nurse moves on to?

Answer 29

can the patient wait?

Question 30

What is the criteria for ESI level 2?

Answer 30

If the patient does not meet the criteria for ESI 1, but should not wait

Question 31

What are the three broad questions to ask to determine if the patient meets the criteria for ESI level 2?

Answer 31

- Is this a high level situation? - Is the patient confused, lethargic, or disoriented? - Is the patient in severe pain or distress?

Question 32

True or false | High risk patients do not require a detailed physical assessment or even a full set of vitals

Answer 32

true

Question 33

An ESI level 2 patient must remain a high priority with assessment and treatment initiated within __ minutes of arrival

Answer 33

10

Question 34

what are some examples of an ESI level 2 patient? | 6

Answer 34

- active chest pain, suspicious for coronary syndrome, not requiring an immediate life saving intervention, with stable vital signs - needlestick in a healthcare worker - signs of a stroke not meeting level 1 criteria - rule-out ectopic pregnancy, hemodynamically stable - a patient on chemotherapy with a fever (immunocompromised) - suicidal or homocidal patient

Question 35

When determining if a patient is confused, lethargic, or disoriented, what are two things to consider?

Answer 35

- Is this an acute change in level of consciousness? | - patients with a baseline of confusion do not meet level 2 criteria.

Question 36

describe confused

Answer 36

inappropriate response to stimuli, decrease in attention span and memory

Question 37

describe Lethargic

Answer 37

drowsy, sleeping more than usual, responds appropriately when stimulated

Question 38

describe disoriented

Answer 38

the patient is unable to answer questions correctly about time, place, or person

Question 39

name three examples of a patient who is confused, lethargic, or disoriented, and give an example of underlying cause

Answer 39

- New onset of confusion in an elderly patient - A three month old whose mother reports the child is sleeping all of the time - an adolecent that is found confused and disoriented - The brain may be structureally or chemically compromised

Question 40

although it is a deciding factor, an ESI level of 2 does not have to be assigned on ____ alone

Answer 40

pain

Question 41

what are three things to consider when assessing pain severity?

Answer 41

- certain pain locations are more likely to predict life-threatening conditions - severe pain may predict a more dangerous problem and require more timely pain control and definitive interventions - acute pain is more likely to be dangerous than chronic or recurrent pain

Question 42

Once determined that a patient does not meet the criteria for an ESI of 1 or 2, what is the next question to move on to?

Answer 42

How many resources will be needed in order for a physician to reach a disposition decision? admit discharge transfer

Question 43

Name some examples of services that are considered resources. (9)

Answer 43

- Labs (any combination = 1 resource) - EKG - x-ray - CT, MRI, US, - IV fluid - IV, IM, or nebulized medications - specialty consultation - Simple procedures such as laceration repair, foley cath - Complex procedures = 2 resources

Question 44

Name some examples of services that are not considered resources. (9)

Answer 44

- History and physical (including pelvic exam) - point of care testing - saline or heplock (although IV fluids are considered resources for hydration) - PO medications - Tetanus immunizations - Prescription refills - phone call to PCP - Simple wound care (dressings) - crutches, splints, slings

Question 45

ESI level __ require two or more resources

Answer 45

3

Question 46

ESI level __ require one resource

Answer 46

4

Question 47

ESI level __ require no resources

Answer 47

5

Question 48

ESI level __ and __ can mostly be taken care of by a PA or NP in a fastrack setting

Answer 48

4 and 5

Question 49

A patient with an ESI level of 3 maybe upgraded to 2 under what conditions

Answer 49

abnormal VS outside of normal parameters, at the discretion of the triage nurse

Question 50

what are the three vital signs used when triaging a patient? For children under __ years, ____ is also used

Answer 50

pulse, respiratory rate, and spO2 saturation. | Children under 3 body temperature is also used

Question 51

A 6 month old baby with a respiratory rate of 48 could have what ESI rating?

Answer 51

either 2 or 3

Question 52

Temperature is only included with children under __ and should exclude ESI level less acute than __

Answer 52

3 | 3

Question 53

The following questions should be answered and are key components of ESI level 2 criteria (3)

Answer 53

- Is this a high risk situation? - Is the patient experiencing new onset confusion, lethargy, or disorientation? - Is the patient experiencing severe pain or distress?

Question 54

When is chest pain treated as non-cardiac?

Answer 54

after it has been proven otherwise

Question 55

A 30 year old with bright red blood per rectum, normal vital signs, and no other risk factors should get a triage level of __

Answer 55

3

Question 56

An elderly patient who called an ambulance because he started vomiting blood and has a heart rate of 117 and a respiratory rate of 24 meets the ESI criteria for level __

Answer 56

2

Question 57

Name 5 cardiovascular high risk situations

Answer 57

- chest pain/SOB - epigastric discomfort - Hypertensive crisis - Hx of angioplasty - Very rapid or slow heart rates

Question 58

chest pain is always ESI level __ and by AHA standards should have an EKG done within __ minutes

Answer 58

2 | 10

Question 59

A 54 year old obese female who presents to the ED with epigastric pain and fatigue is at risk for ____ ____ ____ and should be assigned to ESI level __

Answer 59

acute coronary syndrome | 2

Question 60

Patients wiht chest pain that are physiologically unstable and require immediate intervention such as intubation or hemodynamic support should be triaged as __

Answer 60

1

Question 61

Other high risk cardiovascular situations include | 3

Answer 61

- hypertensive crisis - Acute vascular arterial occlusion - fever in a post valve replacement patient

Question 62

What is a EENT high risk situation affecting an age group of 2-4 years and 20-40 years of age, with patients presenting in a "sniffing" position, inspiratory stridor, and may result in death if not treated quickly

Answer 62

epiglottitis | - note; do not inspect the throat

Question 63

what are three possible causes for epistaxis and what ESI level should they be assigned?

Answer 63

hypertensive crisis anticoagulants recent cocaine use ESI level 2

Question 64

Patients with inhalation injuries shoudl be considered high risk for potential airway compromise. If the patient presents with significant airway distress and requires immediate intervention, they meet the criteria for ESI level __

Answer 64

1

Question 65

Facial trauma with actual airway compromise should be triaged as ESI level __

Answer 65

1

Question 66

Testicular pain gets an ESI level of __

Answer 66

2 | because it could be testicular torsion

Question 67

Patients with epistaxis should have this included with initial vital signs

Answer 67

blood pressure

Question 68

Patients with compartment syndrome should be assigned an ESI level __

Answer 68

2

Question 69

Patients with possible fractures of the pelvis, femur, hip, and extremity dislocations should be assigned an ESI level of __ if they become hemodynamically unstable

Answer 69

1

Question 70

Name 7 high risk situations in Pediatrics

Answer 70

- Seizures - Sepsis, severe dehydration - Diabetic ketoacidosis - child abuse, burns - Head trauma - vitamin/iron or other overdoses/ingestions - infant less than 28 days of age with fever of 100.4F or 38C or greater, which will require a sepsis workup

Question 71

Chronic dementia and confusion do not meet criteria for ESI level __, but is the patients Hx is unknown and the patient presents with confusion, lethargy, disorientation, assume the conditon is new and assign the ESI level of __

Answer 71

2 | 2

Question 72

fever in a patient less than 4 months assign an ESI level of __ if temp is higher than 38C, or 100.4F if there is no obvious source of fever.

Answer 72

3

Question 73

"I am about 6 weeks pregnant and I think I am having a miscarriage", reports a healthy looking 28 yo female. "started spotting this morning and now I am cramping. No allergies or PMHx medications; prenatal vitamins VS 98F, HR112, RR22, BP 90/60

Answer 73

This patient meets the criteria for being up triaged from a level 3 to 2 based on her vital signs. These factors could indicate internal bleeding from a ruptured ectopic pregnancy.

Question 74

"My baby has had diarrhea since yesterday. The whole family has the GI bug that is going around" reports the mother of a 15 month old. The bay has a decreased appetite, a low grade temp, and numerous liquid stools. The baby is sitting quietly on the mothers lap. Signs of dehydration are noted. No PMHx, NKDA, no medications. VS 100.4F, HR 142, RR 48, HR 142, BP 76/50

Answer 74

The patient at least meets the criteria for at least ESI 3 for resources he would require labs and IV fluids. Based on his VS the nurse can upgrade him to a level 2, being that both his HR and RR are not within normal limits.

Question 75

"I need to see a doctor for my cough. I just can't seem to shake it. Last night I didn' get much sleep because I was coughing so much, I am just so tired," reports a 57 yo female. She tells you she had a temperature of 101F last night and is coughing up yellow mucus. Her Hx includes a hysterectomy 3 years ago, takes no medication but is allergic to PCN. VS are 101F, RR 28, HR 100, SpO2 90%

Answer 75

At the beginning of her triage assessment, this patient sounds like she could have PNA. She will need two or more resources but her low O2 and RR are a concern. After looking at her vital signs the triage nurse should upgrade her to an ESI 2

Question 76

A 34 year old female presents to triage complaining of generalized abdominal pain 6/10 for 2 days. She has vomited several times and states her last bowel movement was 3 days ago. She has a Hx of back Sx, takes o medicaitons, and has an allergy to peanuts. Her VS are 97.8F, HR 104, RR 16, BP 132/80, SpO2 99%.

Answer 76

This patient will need a minimum of 2 or more resources, lab, IV fluids, perhaps IV medication for nausea, and a CT scan. The triage nurse would review the patients VS and consider the HR. The HR falls just outside the accepted parameter for the age of the patient but could be due to pain or excersion. In this case the decision should be to assign the patient to a level of 3

Question 77

A tearful 9 yo presents to triage with her mother. She sliped on an icy sidewalk and injured her right forearm. The forearm is obviously deformed but has good color, sensation, and movement. The mother reports she has no allergies and takes no medications, and is healthy. VS are BP 100/68, HR 124, RR 32, and SpO2 99%.

Answer 77

This patient is experiencing pain from a fall and is obviously upset. She will require at least two resources; x-ray and orthopedic consult, and perhaps conscious sedation. Her heart rate and respiratory rate are elevated, but the triage nurse should feel comfortable assigning this patient to ESI level 3. Her VS are likely due to pain and stress.

Question 78

A 72 yo patient presents to the emergency room with her O2 via n/c for her advanced COPD. She informs the triage nurse that she has an infected cat bite on her left hand. The hand is red, tender, and swollen. The patient has no other medical problems, uses an inhaler PRN, and takes an ASA daily, NKDA. VS are 99.6 F, HR 88, RR 22, BP 138/80, SpO2 91%, and denies any respiratory distress.

Answer 78

This patient will require two or more resources; labs and ABx. She meets the criteria for ESI level 3. The triage nurse notices that her O2 saturation and respiratory rate are outside the accepted parameters for an adult but this patient has advanced COPD. These VS are not a concern so the patient will not be up-triaged but will stay an ESI level 3.

Question 79

PB patients less than __ weeks will be evaluated in the ED.

Answer 79

20

Question 80

OB patients more than 20 weeks who present with complaints unrelated to the pregnancy (will/ will not) be evaluated in the ED

Answer 80

they will be evaluated in the ED

Question 81

OB patients more than 20 weeks with OB related symptoms will be evaluated for ____ ____, recieve a short triage and transferred to OB via wheelchair if ____.

Answer 81

presenting parts | stable

Question 82

OB patients who are unstable regardless of pregnancy duration will be handled to who?

Answer 82

ED physician

Question 83

What are 4 things to know about student drug testing in the ED

Answer 83

- Public school students only have to be suspected of being under the influence - consent from the parent or gaurdian is not required - student must be accompanied by a representitive of the school - triage nurse will notify Occupational health during normal business hours or the on call person after hours

Question 84

what is the Safe Haven policy? | 3

Answer 84

- infants 30 days or less can be given to the hospital by parent, no questions asked - Take the infant and confirm that it is being given voluntarily - If the infant appears abused, neglected, or older than 30 days, contact the police.

Question 85

What ESI level for a patient with Chest pain, suspicious of coronary syndrome, with stable vitals

Answer 85

ESI 2

Question 86

What ESI level for a patient who is Healthcare worker with a needlestick

Answer 86

ESI 2

Question 87

What ESI level for a patient with Signs of a stroke

Answer 87

ESI 2

Question 88

What ESI level for a patient with R/O ectopic pregnancy

Answer 88

ESI 2

Question 89

What ESI level for a patient with Fever in the immunocompromised

Answer 89

ESI 2

Question 90

What ESI level for a patient with Suicidal or homicidal ideation

Answer 90

ESI 2

Question 91

What ESI level for a patient with Change in mental status

Answer 91

ESI 2

Question 92

What ESI level for a patient with Testicular torsion

Answer 92

ESI 2

Question 93

What ESI level for a patient with Spontaneous pneumothorax with elevated RR rate

Answer 93

ESI 2

Question 94

What ESI level for a patient with Seizure

Answer 94

ESI 2

Question 95

What ESI level for a patient with Patient in severe pain

Answer 95

ESI 2

Question 96

What ESI level for a patient with Hypertensive crisis

Answer 96

ESI 2

Question 97

What ESI level for a patient with Peritonsillar abscess

Answer 97

ESI 2

Question 98

What ESI level for a patient with Inhalation injury with airway compromise

Answer 98

ESI 2

Question 99

What ESI level for a patient with Hypo/Hyperglycemia

Answer 99

ESI 2

Question 100

What ESI level for a patient with Sepsis

Answer 100

ESI 2

Question 101

What ESI level for a patient with Syncope

Answer 101

ESI 2

Question 102

What ESI level for a patient with Urinary retention

Answer 102

ESI 2

Question 103

What ESI level for a patient with Sudden change or loss in vision

Answer 103

ESI 2

Question 104

What ESI level for a patient with Chemical splash to eyes

Answer 104

ESI 2

Question 105

What ESI level for a patient with Hip / extremity dislocation

Answer 105

ESI 2

Question 106

What ESI level for a patient with Pelvic /Femur fracture

Answer 106

ESI 2

Question 107

What ESI level for a patient with Infant > 28 days with a fever

Answer 107

ESI 2

Question 108

What ESI level for a patient with Accidental/intentional ingestion

Answer 108

ESI 2

Question 109

What ESI level for a patient with Severe respiratory distress

Answer 109

ESI 2

Question 110

What ESI level for a patient with Overdose with respirations <6

Answer 110

ESI 1

Question 111

What ESI level for a patient with Severe bradycardia/tachycardia with hypotension

Answer 111

ESI 1

Question 112

What ESI level for a patient with Traumatic injury with hypotension

Answer 112

ESI 1

Question 113

What ESI level for a patient with Anaphylactic reaction

Answer 113

ESI 1

Question 114

What ESI level for a patient with Hypoglycemia with change in mental status

Answer 114

ESI 1

Question 115

What ESI level for a patient with Chest pain, diaphoretic, with hypotension

Answer 115

ESI 1

Question 116

What ESI level for a patient with Baby that is flaccid

Answer 116

ESI 1

Question 117

What ESI level for a patient with Cardiac arrest

Answer 117

ESI 1

Question 118

What ESI level for a patient with Respiratory arrest

Answer 118

ESI 1

Question 119

What ESI level for a patient with Emergency Bipap

Answer 119

ESI 1

Question 120

Resource or not a resource? | -Labs (any combination = 1 resource)

Answer 120

Resource

Question 121

Resource or not a resource? | -EKG

Answer 121

Resource

Question 122

Resource or not a resource? | x-ray

Answer 122

Resource

Question 123

Resource or not a resource? | Cat scan

Answer 123

Resource

Question 124

Resource or not a resource? | MRI

Answer 124

Resource

Question 125

Resource or not a resource? | Ultrasound

Answer 125

Resource

Question 126

Resource or not a resource? | -IV fluid

Answer 126

Resource

Question 127

Resource or not a resource? | IV, IM, or nebulized medications

Answer 127

Resource

Question 128

Resource or not a resource? | -specialty consultation

Answer 128

Resource

Question 129

Resource or not a resource? | Simple procedures such as laceration repair, foley cath

Answer 129

Resource

Question 130

Resource or not a resource? | Complex procedures

Answer 130

2 resources HA! Got you, didn't I?

Question 131

Resource or not a resource? | History and physical (including pelvic exam)

Answer 131

Not a resource

Question 132

Resource or not a resource? | point of care testing

Answer 132

Not a resource

Question 133

Resource or not a resource? | saline or heplock (although IV fluids are considered resources for hydration)

Answer 133

Not a resource

Question 134

Resource or not a resource? | PO medications

Answer 134

Not a resource

Question 135

Resource or not a resource? | Tetanus immunizations

Answer 135

Not a resource

Question 136

Resource or not a resource? | -Prescription refills

Answer 136

Not a resource

Question 137

Resource or not a resource? | phone call to PCP

Answer 137

Not a resource

Question 138

Resource or not a resource? | Simple wound care (dressings)

Answer 138

Not a resource

Question 139

Resource or not a resource? | crutches, splints, slings

Answer 139

Not a resource