Triage

Question 1

Why use triage?

Answer 1

• It takes 3 mins to triage a pt
• ability to sort out the critical care pts faster
• nurse initiated care can deescalate their scale

Question 2

What is the Australiasia triage scale?

Answer 2

Cat 1 = immediately
Cat 2 = 10 mins
Cat 3 = 30 mins
Cat 4 = 60 mins
Cat 5 = 120 mins

Question 3

Cat 1?

Answer 3

= Very severe (Immediately)

• obstructed airway
• severe resp distress/ absent resp
• severe haemodynamic compromised
  o absent peripheral pulses
  o skin pale, moist, mottled
  o cap refill > 4
• uncontrolled haemorrhage
• HR < 60 paediatric
• GCS < 8

Question 4

Cat 2:

Answer 4

= Severe (10 mins)

• Patent airway
• moderate resp distress
• moderate haemodynamic compromised
  o thready pulse
  o cap refil 2-3 sec
• GCS 9-12
• Severe pain

Question 5

Cat 3:

Answer 5

= moderately severe

• Mild resp distress
• mild haemodynamic compromised
  o altered vital signs
  o skin warm, pale
• GCS > 13
• Moderate pain
• moderate neurovascular compromise

Question 6

Cat 4:

Answer 6

= moderate (60 mins)
- airway patent
- no resp distress, no haemodynamic comrpromise
- normal GCS
- mild pain
- Mild Neuro compromise

Question 7

Cat 5:

Answer 7

= Minimal (120 mins)

• Airway patent
• no distress
• normal GCS
• no pain
• no Neuro compromise

Question 8

What does a triage nurse do?

Answer 8

• perform quick assessment
• prioritise
• function under stress
• communication
• think ahead
• control pt flow
• diffuse conflict
• initiate first aid