Fast Facts for the Triage Nurse, Second Edition

Lynn Sayre Visser, MSN, RN, PHN, CEN, CPEN, FAEN has devoted her 28 year career to emergency nursing, triage education, mentoring others, and writing about topics that impact nursing. Her career has been complemented by experience in prehospital care, ICUs, post-anesthesia care units, and as an organ procurement coordinator. Her passion for quality patient care led her to play instrumental roles in the implementation of a provider in triage, rapid triage assessment, and immediate bedding processes along with formalized triage education in multiple facilities. She is a change-agent and philanthropist and has been published in a variety of arenas. She is the co-author of Fast Facts for the Triage Nurse: An Orientation and Care Guide, Essentials for the Triage Nurse, Rapid Access Guide for Triage and Emergency Nurses, and Rapid Access Guide for Pediatric Emergency Nursing. Her work has been recognized with two American Journal of Nursing Book of the Year awards, the 2019 Emergency Nurses Association (ENA) Media Award, the 2021 ENA Team Award, as well as the 2019 Sigma Theta Tau Edith Moore Copeland Founders Award for excellence in creativity. She holds a Master of Science Degree in Nursing with an emphasis in education and a double Bachelor of Science degree in nursing and exercise physiology. Anna Sivo Montejano, DNP, RN, PHN, CEN, has over three decades of experience in emergency nursing and triage education. She has taught nursing theory and aided the professional development of nurses as a preceptor, mentor, and clinical instructor. She has been a certified emergency nurse for more than 30 years. Her ED contributions include work as a staff nurse, primary preceptor, and assistant nurse manager, as well as in educational development. Dr. Montejano has worked to improve the quality and efficiency of patient care through projects such as the change process of rapid medical screenings and rapid triage assessments; as a project manager for a major ED expansion; and as an advanced cardiac life support instructor. She authored Fast Facts for the Triage Nurse: An Orientation and Care Guide in a Nutshell, which won third place in the 2015 American Journal of Nursing Book of the Year awards in the critical care/emergency category, the Emergency Nursing Association, Media award in 2019, and the Assessment Technologies Institute (ATI) Nurse Educator of the Year. This book has since become available in the United Kingdom under the title Essentials for the Triage Nurse: An Orientation and Care Guide. She has her Doctor of Nursing Practice degree from California State University, Northern Consortium (Fresno and San Jose State University), her Master's Degree in Nursing with a focus on education, and her Bachelor of Science degree.

Reviewers


Foreword Rebecca S. McNair, RN, CEN


Preface


~A Heartfelt Thank You~


Acknowledgments


Part I SETTING THE STAGE FOR SUCCESS AT TRIAGE


1. Orienting to Triage


Lynn Sayre Visser


2. Precepting at Triage


Lynn Sayre Visser


3. Tips for Success at Triage


Lynn Sayre Visser and Anna Sivo Montejano


4. Personal Awareness for the Triage Nurse


Anna Sivo Montejano


5. Triage Competency


Shelley Cohen


Part II POINT-OF-ENTRY PROCESSES IN TRIAGE NURSING


6. The Patient Arrival


Anna Sivo Montejano


7. The Patient Experience in Triage Nursing


Lynn Sayre Visser


8. Legal Concerns in Triage Nursing


Deb Jeffries


Part III NURSING ESSENTIALS FOR EFFECTIVE TRIAGE


9. Triage Acuity Scales


Deb Jeffries


10. Triage Documentation


Rebecca S. McNair


11. Time-Sensitive Medical Conditions


Lynn Sayre Visser


Part IV CURRENT TRENDS IMPACTING TRIAGE NURSING


12. Urgent Care Triage


Valerie Aarne Grossman


13. Electronic Medical Record Considerations


Dawn Friedly Gray


14. Provider in Triage


Lynn Sayre Visser


15. Advanced Triage Protocols


Dawn Friedly Gray


Part V “RED FLAG” PATIENT PRESENTATIONS


16. Introduction to “Red Flag” Presentations


Lynn Sayre Visser


17. Respiratory Emergencies


Polly Gerber Zimmermann and Lynn Sayre Visser


18. Cardiac Emergencies


Polly Gerber Zimmermann


19. Neurological Emergencies


Reneé Semonin Holleran


20. Abdominal Emergencies


Polly Gerber Zimmermann and Lynn Sayre Visser


21. Obstetric and Gynecological Emergencies


Lynn Sayre Visser and Polly Gerber Zimmermann


22. Behavioral Health Emergencies


Anna Sivo Montejano


23. Ocular Emergencies


Anna Sivo Montejano and Lynn Sayre Visser


24. Musculoskeletal Emergencies


Reneé Semonin Holleran


25. Endocrine Emergencies


Dawn Friedly Gray


26. Environmental Emergencies


Anna Sivo Montejano


27. Trauma Emergencies


Reneé Semonin Holleran


28. Infectious Presentations


Anna Sivo Montejano and Lynn Sayre Visser


Part VI SPECIAL CONSIDERATIONS IN TRIAGE NURSING


29. Special Populations in Triage


Anna Sivo Montejano


30. Pediatric Triage


Deb Jeffries


31. Older Adult Triage


Anna Sivo Montejano


32. Pain Management at Triage


Reneé Semonin Holleran


33. Patient and Staff Safety


Anna Sivo Montejano


34. Case Studies in Triage Nursing


Anna Sivo Montejano and Lynn Sayre Visser


Part VII DISASTER SITUATIONS IN TRIAGE NURSING


35. Emergency Management: A Triage Nurse’s Guide for When Disaster Strikes


Erik Angle


36. Active Shooter or Active Violence


Erik Angle


Abbreviations


Appendix A: Resources


Appendix B: Triage Competency Validation Form


Appendix C: Sample Triage Education and Competency Plan


Appendix D: Sample Triage Retrospective Chart Review Audit Form


Appendix E: Disaster Triage Tag


Additional Reading


Index