Triage: Identifying the Client Requiring the Most Immediate Care in the Burn Unit
Introduction
Triage is the process of prioritizing patients based on the severity of their injuries or illnesses. In the burn unit, triage is essential to ensure that the patients with the most critical needs receive care first.
Nurse Troyzan has just received the change-of-shift report in the burn unit. There are several patients on the unit, but Nurse Troyzan needs to identify the client who requires the most immediate care.
Triage Assessment
Nurse Troyzan will perform a triage assessment on each patient to assess the severity of their injuries and determine their level of need. The triage assessment will include the following:
- Vital signs: Nurse Troyzan will check the patient’s vital signs, including temperature, heart rate, respiratory rate, and blood pressure. Vital signs can provide important information about the patient’s overall health and the severity of their injuries.
- Airway: Nurse Troyzan will assess the patient’s airway to ensure that it is patent (open). If the patient has an airway obstruction, it is a medical emergency and must be cleared immediately.
- Breathing: Nurse Troyzan will assess the patient’s breathing to ensure that they are able to breathe adequately. Nurse Troyzan will also look for any signs of respiratory distress, such as shortness of breath, wheezing, or cyanosis (bluish discoloration of the skin).
- Circulation: Nurse Troyzan will assess the patient’s circulation to ensure that they have adequate blood flow. Nurse Troyzan will check the patient’s capillary refill time, pulse, and blood pressure.
- Disability: Nurse Troyzan will assess the patient’s level of consciousness and responsiveness. Nurse Troyzan will also assess the patient’s neurological status, including their pupils, motor strength, and sensory function.
- Exposure: Nurse Troyzan will completely expose the patient’s body to assess the severity of their burns. Nurse Troyzan will also look for any other injuries that may not be immediately apparent.
Identifying the Client Requiring the Most Immediate Care
Once Nurse Troyzan has completed the triage assessment on each patient, they will need to identify the client who requires the most immediate care. The client who requires the most immediate care is the client who is at the highest risk of death or serious complications.
Nurse Troyzan will consider a number of factors when identifying the client who requires the most immediate care, including:
- Airway: If any client has an airway obstruction, they will require the most immediate care.
- Breathing: If any client is experiencing respiratory distress, they will require the most immediate care.
- Circulation: If any client has inadequate blood flow, they will require the most immediate care.
- Disability: If any client has a decreased level of consciousness, neurological impairment, or severe burns, they will require the most immediate care.
Conclusion
Nurse Troyzan will use their critical thinking skills to assess the triage assessment findings and identify the client who requires the most immediate care. The client who requires the most immediate care is the client who is at the highest risk of death or serious complications.
Additional Information
In addition to the above, Nurse Troyzan should also consider the following factors when identifying the client who requires the most immediate care:
- Age: Infants, young children, and older adults are at an increased risk of complications from burns.
- Medical history: Clients with underlying medical conditions, such as diabetes or heart disease, are at an increased risk of complications from burns.
- Mechanism of injury: Clients who have sustained burns from inhalation injuries, electrical injuries, or chemical burns are at an increased risk of complications.