application of ctas

7/29/2019 Application of CTAS

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Application of C.T.A.S


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Scenario 1

EMS arrives with a 76-year-old male foundon the bathroom floor. The family called

997 when they heard a loud crash in thebathroom. The patient was found in hisunderwear and the toilet bowl was filled

with maroon-colored stool.


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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 thinhis blood."


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What triage category would youallocate to this patient.?

For how long your patient can waitbefore being seen by a physicianaccording to this triage category?

Where will you allocate this patient?


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CTAS Triage Level 1

requires immediate lifesaving intervention

This 76-year-2.old patient is in hemorrhagic shockfrom his GI bleed. His blood pressure is 70, his heartrate is 128 and his respiratory rate is 40, all indicatingan attempt to compensate for his blood loss. Heprobably takes warfarin (Coumadin) for his atrial

fibrillation. This patient needs immediate IV accessand the administration of fluid, blood, andmedications.


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Scenario 2

Scenario 2

An 67 yr old woman presents with anoticeable left sided facial droop and

complaining of facial pain. Vital Signs

Pulse: 76 RR: 20 BP: 110/70 Temp: 38

Patient on antibiotic for URTI 2 days


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What triage category would you allocateto this patient.?

For how long your patient can wait beforebeing seen by a physician according tothis triage category?



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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 byfirst checking for extremity movement and strength. (anyweakness limb or arm). alternative causes for this patientsymptoms such as bells palsy or local trauma.


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Scenario 3

70-year-old female with her right arm in a cast is broughtto triage by her daughter. The daughter states her motherfell 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 athome and thinks her mother is in pain.Patient has a history of Alzheimer's disease. The patient isconfused, mumbling (per baseline); face flushed.

She is unable to provide verbal description of hercomplaints. Her right upper extremity is in a short armcast; digits appear tense, swollen and ecchymotic. Nailbeds are pale; capillary refill delayed. Patient is notwearing a sling.


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What are the assessment related to thiscase?


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TRIAGE level 2.High risk for compartment syndrome.Despite the patient being a poor historian, the triage nurseshould 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


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Scenario 4

A 63-year-old cachectic male is brought infrom the local nursing home because his

feeding tube was removed again. Thepatient is usually unresponsive. He hasbeen in the nursing home since he suffereda massive stroke about 4 years ago.


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TRIAGE level 4: one resource.This patientwill be sent back to the nursing home after

the feeding tube is reinserted. There is noacute change in his medical condition thatwarrants any further evaluation. Yes, he isunresponsive but that is the patient'sbaseline mental status so he is not an CTASlevel 1.


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Scenario 5

A 72-year-old female with Bronchial Asthmaand increased work of breathing is wheeled

into triage. Between breaths she tells youthat she "is having a hard time breathingand has had a fever since yesterday." TheSpO2monitor is alarming and displaying asaturation of 84 percent.


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ER beds are full that time, in this casewhats your nursing care?


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TRIAGE level 1:

Immediate aggressive airway management is what thispatient requires. Her saturation is very low and she

appears to be tiring. The triage nurse does not need theother vital signs in order to decide that this patient needsimmediate care.

Oxygenation and keep saturation level above 90%

And give steroidal medications ASAP per doctor order.


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Scenario 6

A28-year-old male presents with a chief complaintof tearing and irritation to the right eye. He is aconstruction worker and was drilling concrete. He

states "I feel like there is something in my eye"and reports "irrigated the eye several times but itdoesn't feel any better." Patient appears in nosevere distress; however, he is continually rubbinghis eye. Right eye appears red, irritated, with

excessive tearing.

Vital Signs are stable.


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What are the nursing intervention whenthere is no available beds?


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Level 2.High risk for severe alkaline burn.Concrete is an alkaline substance and

continues to burn and penetrate thecornea causing severe burns. Alkalineburns are more severe than burns with

acid substances and require irrigation withvery large amounts of fluids


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Scenario 7

A 34-year-old male presents to triage withright lower quadrant pain, 4/10 all day.

Pain is associated with loss of appetite,nausea and vomiting. PMH: None. Thepatient appears in moderate discomfort,

skin warm and dry, guarding abdomen. Temp:37 PULSE: 86 RES: 20 BP: 110/72


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For how long your patient can wait beforebeing 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?


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TRIAGE 3.However, the patient could beupgraded to triage 2 if vital signs were abnormal, i.e., heart rate greater

than 100. Signs of acute appendicitis include mild-to-severe RLQ pain with loss of appetite, nausea,

vomiting, low-grade fever, muscle rigidity, and LLQpressure that intensifies the RLQ pain. The presenceof all these symptoms and tachycardia would indicatea high risk for a surgical emergency.

Modifier VS , PS + Assessment


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Scenario 8

. "I ran out of my blood pressure medicineand my doctor is on vacation. Can

someone here write me a prescription?"requests a 56-year-old male with a historyof DM.

VS: BP 128/84, HR 76, and RR 16, T 36.1

C.RBS:20


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TRIAGE level 5: no resources.The patient needs aprescription refill and has no other medical complaints.

His blood pressure is controlled with his currentmedication. 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 totriage level 2. If this patient's BP was elevated and thepatient had no complaints, he or she would still remainan CTAS level 5. The blood pressure would be repeatedand would most likely not be treated in the ED or treated

with PO medications.


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Scenario 9

"My mother is just not acting herself,"reports the daughter of a 72-year-old

female. "She is sleeping more than usualand complains that it hurts to pee."

VS: T 38.2 C, HR 98, RR 22, BP 122/80.

The patient responds to verbal stimuli butis disoriented to time and place.


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TRIAGE level 2: new onset confusion, lethargy,or disorientation.The daughter reports that hermother has a change in level of consciousness.The reason for her change in mental status maybe a urinary tract infection that has advanced tobacteremia. She has an acute change in mental

status and is therefore high risk.


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Scenario 10

EMS arrives with a 75-year-old male witha self-inflicted 6-cm laceration to his neck.

Bleeding is currently controlled. With tearsin his eyes, the patient tells you that hiswife of 56 years died last week. Healthy,

NKDA, baby ASA per day, BP 136/82, HR74. RR 18, SpO296% RA.


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TRIAGE level 2: high risk.This 75-year-old maletried to kill himself by cutting his throat. Becauseof the anatomy of the neck, this type of

laceration has the potential to cause airway,breathing, and/or circulation problems. At thesame time, he is suicidal and the ED needs toensure that he does not leave or attempt to

harm himself further.

application of ctas

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