Learning Objectives
By the end of this section, you will be able to:
- Define triage and the nursing responsibility related to triage
- Discuss the ABCDE assessments utilized in triage
- Use prioritization findings to guide nursing care
- Define components of effective documentation in the emergency department
- Explain patient consent in the event of an emergent event
Nurses should be prepared to respond to an emergency at any time. Most emergent conditions are treated by emergency department nurses in the hospital’s emergency rooms. In addition to working in a fast-paced, ever-changing environment, ED nurses need exceptional assessment, prioritization, and critical thinking skills. The Joint Commission (2023) seeks to increase the quality of patient care in the ED and improve patient outcomes. This is achieved through accurately assessing and triaging patients, which reduces time spent waiting and being treated in the ED.
Clinical Judgment Measurement Model
Recognizing Cues in a Patient in the ED
The nurse in a busy ED is assessing a fifty-six-year-old male patient who reports chest pain radiating to the left arm. The nurse asks the patient to rate the pain on the numerical pain scale, documenting a rating of 8/10. The nurse also notes that the patient is diaphoretic and appears anxious. The nurse records the patient’s vitals at intake: BP: 148/90; HR: 111 bpm; RR: 23; and O2 sat: 96 percent on RA. It is important for the nurse to identify the cues from the patient assessment, such as the chest pain, BP, and HR, that indicate there is a problem and then analyze those cues to determine the next steps.
Triage
The term triage refers to the process of assessing and prioritizing patients’ care based on initial assessment findings. Nurses must be able to effectively and efficiently triage patients, especially in emergency situations. For example, a person who has chest pain would be prioritized before a patient with an ankle injury. Nurses understand that chest pain could be indicative of a myocardial infarction (MI) or heart attack, and while an ankle fracture is painful, it is not as life threatening as an MI. Triage occurs during initial intake phase, whenever there is a change in a patient’s condition, and during situations with mass casualties.
During the triage phase, the nurse has several responsibilities. The first is to complete an assessment to determine immediate concerns. This involves asking questions, using clinical judgment to recognize cues, analyzing cues, and prioritizing findings. The nurse will also review the patient’s medical history, if possible, to determine if any current concerns are related to previously identified conditions or comorbidities. Based on the severity of findings, the nurse will then prioritize care and take action, implementing interventions to address any identified concerns. The nurse will also follow any provider orders, such as administering medications or collecting blood samples for diagnostic testing. While conducting triage, the nurse should remember to ensure that the patient’s privacy is protected.
Cultural Context
Respecting Modesty and Privacy
When undergoing a comprehensive assessment in the emergency department, the patient will need to have their clothing removed. The ED nurse will need to be respectful of the privacy and modesty of all patients, whether they are conscious or unconscious. In addition, the nurse should always be aware that modesty can have an important role in many religions and cultures. For example, modesty is greatly emphasized in the Muslim religion. A Muslim patient may prefer to be treated by a provider of the same sex, when possible (Attum et al., 2023). In an emergency situation, it may not be possible to accommodate provider preference. In this case, the nurse can advocate for the patient by ensuring that a same-sex staff member or, if possible, a family member, is present during the exam. If the patient’s clothing must be removed and modesty cannot be maintained, providers should try to expose as little of the patient’s body as possible and restore coverage as soon as possible.
Additional steps that the nurse can take to preserve the modesty and privacy of all patients include closing patient curtains and doors before removing any clothing. If the patient is unconscious or unable to respond, politely ask anyone other than health-care staff to leave the room before assessing the patient. If the patient is alert and can respond appropriately, ask if they feel comfortable disrobing with others present in the room. When performing the assessment, provide a gown, drape, or blanket to cover private areas when the patient is not being assessed. Emergency departments tend to be very busy, and sometimes simple gestures such as these get lost in the shuffle. Before anything else, nurses are patient advocates, and they need to make sure respect is always a priority.
Airway, Breathing, Circulation, Disability, and Exposure (ABCDE)
One of the most utilized method for triaging patients in emergency situations is the airway, breathing, circulation, disability, and exposure (ABCDE) triage assessment (Althobity et al., 2024). Each letter represents a step of the assessment, performed in alphabetical order:
- A: Airway
- B: Breathing
- C: Circulation
- D: Disability
- E: Exposure
When using the ABCDE triage method, the airway is assessed first regardless of underlying cause or patient age (Althobity et al., 2024). Emergency airway conditions are always treated first before moving to other areas or body systems.
Airway
The airway is the most important system, because without an adequate airway, the patient’s lungs cannot supply vital oxygen to the rest of the body (Althobity et al., 2024). To be skillful at airway management, the nurse must first understand the structural, physical, and pathological aspects related to the airway (Avva et al., 2024). When assessing the airway, the nurse first checks for patency. This can be done by asking the patient questions and listening to their response. If their voice sounds normal, without obstruction, their airway is patent. If their voice sounds muffled or crackled, there may be an obstruction. In some cases, a decline in level of consciousness can lead to airway obstruction caused by the tongue. The easiest way to open the airway for an unconscious patient is to use the head-tilt and chin-lift method (Figure 33.2). Determining airway patency enables the nurse to either move on to breathing or request the provider initiate an artificial airway.
Breathing
The next step in the ABCDE triage assessment is to assess the patient’s breathing. This can be achieved by counting the patient’s respiratory rate. The nurse should assess whether the patient’s chest rises symmetrically and whether the trachea is midline. The nurse will also determine how much effort it takes for the patient to breathe. This means noting if the patient is using accessory muscles or is displaying pursed lip breathing. Recognizing signs of respiratory distress is critical when assessing breathing status (Avva et al., 2024).
Next, the nurse will auscultate the lungs and apply a pulse oximeter to measure oxygen saturation. If the patient is in respiratory distress, the nurse will utilize emergency equipment, such as a crash cart, bag-mask for ventilation, suction, and an emergency intubation kit, to help stabilize the patient’s breathing. Recommendations for compromised breathing include positioning the patient, providing supplemental oxygenation, and implementing an artificial airway, such as an endotracheal tube for airway management (Raveendra et al., 2020).
Circulation
The third step in the ABCDE triage assessment is circulation. Once the patient’s airway and breathing are stable, assessing for circulation to determine adequate perfusion is critical. First, the nurse should confirm the patient’s apical pulse with a stethoscope. Then, the nurse should check capillary refill time and for any signs of cyanosis or color change of the skin. Systemically assessing all pulse points will help identify any differences among the extremities. The nurse will also collect data, such as the patient’s blood pressure, assessing for hypotension or hypertension. The patient is also placed on an electrocardiogram monitor to assess their cardiac rhythm. At this stage of the triage, intravenous (IV) line access is usually placed if the patient does not already have one. In emergency situations, choose a larger gauge IV in case the need arises for fluid boluses or blood replacements (Verhoeff et al., 2018).
Link to Learning
Often, the emergency room nurse places a patient’s first IV. Watch this video for an overview of different IV gauges and their most common uses.
Disability
The next phase of the ABCDE triage assessment is to assess for disability. In this triage method, disability refers to a patient’s level of consciousness. The Glasgow Coma Scale (GCS) is the most widely used assessment tool for assessing level of consciousness in emergency cases. The GSC assesses eye-opening, verbal, and motor responses to stimuli and provides a range of possible responses to help providers assess neurological deficits (see Table 15.4). There are many factors that can cause a decreased level of consciousness, and the health-care team will need to rule these out before attempting to treat the disability. A few such causes include decreased oxygenation to the brain or hyperventilation from pain, which can result in decreased oxygenation to the central nervous system; too much perfusion to the brain, as in the case of internal hemorrhaging; or a recent administration of analgesics, including prescribed and nonprescribed medications.
Exposure
The final step in the ABCDE triage assessment involves assessing for exposure. Being exposed in this instance can refer to being vulnerable to elements in the environment (such as extreme temperatures) or to harmful substances (chemicals, smoke inhalation, or drugs). The first step is assessing the patient’s body temperature. An extreme hyper or hypo body temperature can be a sign of shock or infection. The nurse needs to assess for signs of underlying bleeding or trauma and skin abnormalities. Make sure to inspect the whole body, including the back and groin for any injuries or rashes. The nurse should initiate any cooling or warming measures if indicated.
Prioritizing Findings of the Triage Assessment
After the recognizing and analyzing of cues has taken place, it is time for the nurse to prioritize the findings. Prioritization can be achieved through many simple steps. The nurse will use a process of elimination—sort of like an algorithm—with each finding of the triage assessment. The following are the basic steps for prioritizing which findings must be addressed first:
- Airway, breathing, circulation (ABC): A patient’s airway, breathing, and circulation must be assessed and prioritized before any other interventions.
- Acute versus chronic signs or symptoms: Acute symptoms (those that are current/recent) take precedence over chronic, long-term symptoms or health conditions. However, the nurse will remain aware of how chronic conditions could affect the patient’s acute problem.
- Expected versus unexpected findings: The nurse needs to assess for expected findings on an exam but also monitor and pay attention to any unexpected findings—particularly if they could be harbingers of complications.
- Does this finding need further assessment, or can an intervention be applied?: The nurse needs to be able to assess whether a finding needs to be explored more or if it’s appropriate to provide an intervention.
- Maslow’s hierarchy of needs: The nurse should be aware of how a patient’s needs, according to Maslow’s hierarchy, influence care. At the most basic level, all patients need to have their physiological needs for food, water, and pain relief met. At the same time, emotional needs, like feeling safe, are also an integral part of patient-centered care.
Any identified immediate needs will be discussed with the provider for collaboration on next steps. After addressing the patients’ immediate needs, the registered nurse will complete a more in-depth, comprehensive assessment.
Components of Effective Documentation
Documentation in the emergency department or during an emergency situation can be challenging. Despite this, it is still crucial for nurses to abide by documentation standards to validate the providing of timely, accurate, and quality care. Documentation involves recording assessment findings. Symptoms, or subjective assessment findings, are those findings that the nurse does not directly observe and are only reported by the patient. These findings can include how the patient feels. By contrast, objective assessment findings, or signs, are aspects that the nurse directly observes and that can be measured. Examples include vital signs, diagnostic tests, physical findings, and the patient’s mental state.
In addition to featuring assessment findings, effective documentation includes past medical and social history, medications, a review of systems, and order acknowledgment. Nurses should also document any communication of the health-care team with the patient or family members, such as nursing education provided, discussion of advance directives, language preference, and performance of medication reconciliation. Nurses must also document plans of care, along with their assessment and evaluation of nursing interventions performed, implementation, and responses and outcomes to patient care.
Documenting timely, accurate, and complete assessments ensures that the information shared among health-care professionals is factual. Many decisions among the interdisciplinary team are based on documentation of every patient encounter. Information written in the patient’s chart should clearly convey the encounter and leave no gaps for assumptions (Lorenzetti et al., 2018). Documentation should also be organized, meaning that the timing of documentation should be in order and be completed as close as possible to the real time of the encounter.
Consent in an Emergency
When patients come into the emergency room and are able to sign documents, the first document they sign is a consent, which gives medical professionals the authority to treat the patient with the most competent and highest quality of care. If a patient is brought to the emergency room and is unable to sign at that time, life-sustaining measures are still provided under implied consent, which means approval is presumed though not obtained during an emergent situation due to the life-threatening nature of the situation.
Treating Minors
Minors, or those under eighteen years of age, are often brought in by parents or legal guardians to be seen in the emergency department. The Emergency Treatment and Labor Act requires that all minors and patients receive a medical screening (American College of Family Physicians, 2023). This law was enacted to determine if a minor’s condition is life-threatening and whether they need emergency care even if they were brought in by a relative or friend instead of a parent or legal guardian. During an emergency, verbal consent from the parent or guardian via the telephone may be obtained. Two witnesses must be listening simultaneously and will sign the consent form, indicating that consent was received via telephone. If the minor needs immediate medical attention and the provider cannot obtain consent from a parent or legal guardian, then they can proceed with treatment. Health-care professionals should be knowledgeable about their individual state laws for treating minors in the emergency department.
Life-Stage Context
Exceptions to Parental Consent
In some states, a mature minor may give consent for certain medical treatments. The provider can make a determination that the adolescent (usually over fifteen years of age) is suitably mature enough and has the appropriate intelligence to make the decision for treatment. The provider will also weigh the severity of the treatment, the risks and benefits of completing the procedure now versus waiting before obtaining consent from a mature minor.
An example of this situation might involve a family taking their child’s sixteen-year-old friend on vacation with them. Suppose the friend trips while ice skating and gets hurt. The parents take the sixteen-year-old minor to the local emergency room for treatment. The minor’s parents are at work and unable to be reached via phone. The health-care team has determined the minor has sustained a broken arm that requires the application of a cast. The minor can give consent on their own behalf for the cast if the provider has deemed the minor mature and knowledgeable enough to provide consent.