Application of C.T.A.

Scenario 1
EMS arrives with a 76-year-old male found
on the bathroom floor. The family called 997 when they heard a loud crash in the bathroom. The patient was found in his underwear and the toilet bowl was filled with maroon-colored stool.

 Vital signs (VS) on arrival:

blood pressure (BP) 70/palpable, heart rate (HR) 128, respiratory (RR) 40. His family tells you he has a history of atrial

fibrillation and takes a "little blue pill to thin his blood."

What triage category would you

allocate to this patient.? For how long your patient can wait before being seen by a physician according to this triage category? Where will you allocate this patient?

 CTAS Triage Level 1

requires immediate lifesaving intervention

This 76-year-2.old patient is in hemorrhagic shock from his GI bleed. His blood pressure is 70, his heart rate is 128 and his respiratory rate is 40, all indicating an attempt to compensate for his blood loss. He probably takes warfarin (Coumadin) for his atrial fibrillation. This patient needs immediate IV access and the administration of fluid, blood, and medications.

Scenario 2
An 67 yr old woman presents with a Vital Signs
Pulse: 76 RR: 20 BP: 110/70 Temp: 38 Patient on antibiotic for URTI 2 days

noticeable left sided facial droop and complaining of facial pain.

 What triage category would you allocate

to this patient.? For how long your patient can wait before being seen by a physician according to this triage category? Where will you allocate this patient?

 Triage Level 3
Patient is needs to be seen as soon as possible but can wait for up to 30 minutes. Patient is stable for the moment but requires re-assessment
Most important for the triage nurse to do:
R/O systemic neurological cause such as a brain attack by first checking for extremity movement and strength. (any weakness limb or arm). alternative causes for this patient symptoms such as bells palsy or local trauma.

Scenario 3
70-year-old female with her right arm in a cast is brought
to triage by her daughter. The daughter states her mother fell yesterday and fractured her arm. The patient is complaining of pain. Daughter states, "They put this cast on yesterday, but I think it's too tight." Daughter reports her mother has been very restless at home and thinks her mother is in pain. Patient has a history of Alzheimer's disease. The patient is confused, mumbling (per baseline); face flushed. She is unable to provide verbal description of her complaints. Her right upper extremity is in a short arm cast; digits appear tense, swollen and ecchymotic. Nail beds are pale; capillary refill delayed. Patient is not wearing a sling.

 What triage category would you allocate

to this patient.? What are the assessment related to this case?

 TRIAGE level 2. High risk for compartment syndrome.

Despite the patient being a poor historian, the triage nurse should be able to identify some of the signs of threatened compartment syndrome: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis. The patient requires immediate limb-saving intervention:
Cutting of the cast and further evaluation for potential compartment syndrome

Scenario 4
A 63-year-old cachectic male is brought in
from the local nursing home because his feeding tube was removed again. The patient is usually unresponsive. He has been in the nursing home since he suffered a massive stroke about 4 years ago.

 What triage category would you allocate

to this patient.? For how long your patient can wait before being seen by a physician according to this triage category?

 TRIAGE level 4: one resource. This patient

will be sent back to the nursing home after the feeding tube is reinserted. There is no acute change in his medical condition that warrants any further evaluation. Yes, he is unresponsive but that is the patient's baseline mental status so he is not an CTAS level 1.

Scenario 5
A 72-year-old female with Bronchial Asthma
and increased work of breathing is wheeled into triage. Between breaths she tells you that she "is having a hard time breathing and has had a fever since yesterday." The SpO2 monitor is alarming and displaying a saturation of 84 percent.

 What triage category would you allocate

to this patient.? ER beds are full that time, in this case whats your nursing care?

 TRIAGE level 1: Immediate aggressive airway management is what this

patient requires. Her saturation is very low and she appears to be tiring. The triage nurse does not need the other vital signs in order to decide that this patient needs immediate care. Oxygenation and keep saturation level above 90% And give steroidal medications ASAP per doctor order.

Scenario 6
A 28-year-old male presents with a chief complaint of tearing and irritation to the right eye. He is a construction worker and was drilling concrete. He states "I feel like there is something in my eye" and reports "irrigated the eye several times but it doesn't feel any better." Patient appears in no severe distress; however, he is continually rubbing his eye. Right eye appears red, irritated, with excessive tearing. Vital Signs are stable.

 What triage category would you allocate

to this patient.? What are the nursing intervention when there is no available beds?

 Level 2. High risk for severe alkaline burn.

Concrete is an alkaline substance and continues to burn and penetrate the cornea causing severe burns. Alkaline burns are more severe than burns with acid substances and require irrigation with very large amounts of fluids

Scenario 7
A 34-year-old male presents to triage with
right lower quadrant pain, 4/10 all day. Pain is associated with loss of appetite, nausea and vomiting. PMH: None. The patient appears in moderate discomfort, skin warm and dry, guarding abdomen. Temp:37 PULSE: 86 RES: 20 BP: 110/72

 What triage category would you allocate

to this patient.? For how long your patient can wait before being seen by a physician according to this triage category? Where will you allocate this patient? What is the most important assessment related to this case?

 TRIAGE 3. However, the patient could be

upgraded to triage 2
if vital signs were abnormal, i.e., heart rate greater than 100. Signs of acute appendicitis include mild-tosevere RLQ pain with loss of appetite, nausea, vomiting, low-grade fever, muscle rigidity, and LLQ pressure that intensifies the RLQ pain. The presence of all these symptoms and tachycardia would indicate a high risk for a surgical emergency.

Modifier VS , PS + Assessment

Scenario 8
. "I ran out of my blood pressure medicine
and my doctor is on vacation. Can someone here write me a prescription?" requests a 56-year-old male with a history of DM. VS: BP 128/84, HR 76, and RR 16, T 36.1 C.RBS:20

 What triage category would you allocate

to this patient.?

 TRIAGE level 5: no resources. The patient needs a

prescription refill and has no other medical complaints. His blood pressure is controlled with his current medication. If at triage his blood pressure was 188/124, and he complained of a headache then he would meet the criteria for a high-risk situation and be assigned to triage level 2. If this patient's BP was elevated and the patient had no complaints, he or she would still remain an CTAS level 5. The blood pressure would be repeated and would most likely not be treated in the ED or treated with PO medications.

Scenario 9
"My mother is just not acting herself,"
reports the daughter of a 72-year-old female. "She is sleeping more than usual and complains that it hurts to pee." VS: T 38.2 C, HR 98, RR 22, BP 122/80. The patient responds to verbal stimuli but is disoriented to time and place.

 What triage category would you allocate

to this patient.? For how long your patient can wait before being seen by a physician according to this triage category? Where will you allocate this patient?

 TRIAGE level 2: new onset confusion, lethargy,

or disorientation. The daughter reports that her mother has a change in level of consciousness. The reason for her change in mental status may be a urinary tract infection that has advanced to bacteremia. She has an acute change in mental status and is therefore high risk.

Scenario 10
EMS arrives with a 75-year-old male with
a self-inflicted 6-cm laceration to his neck. Bleeding is currently controlled. With tears in his eyes, the patient tells you that his wife of 56 years died last week. Healthy, NKDA, baby ASA per day, BP 136/82, HR 74. RR 18, SpO2 96% RA.

 What triage category would you allocate

to this patient.?

 TRIAGE level 2: high risk. This 75-year-old male

tried to kill himself by cutting his throat. Because of the anatomy of the neck, this type of laceration has the potential to cause airway, breathing, and/or circulation problems. At the same time, he is suicidal and the ED needs to ensure that he does not leave or attempt to harm himself further.