急危重癥護理學之急診分診

急危重癥護理學EmergencyandCriticalCare

Nursing《急危重癥護理學》急

診

分

診p.a-trom,he

fd

uin

sar

Sdpss

fata.auy

tt,busTriagecomesfromwar-timemedicine:don'tbotherwiththe

healthy;letthesickestdie;andfocus

onthose

on

the

brink

of

death.《急救護理學》分診Triage·

是指對病情種類和嚴重程度進行簡單、快速的評估與分類，

確定就診的優(yōu)先次序，使病人因為恰

當

的

原

因在恰當?shù)臅r間、

恰當?shù)闹委焻^(qū)獲得恰當

的治療與護理的過程

.《急救護理學》分

診

Triage·Thegoal

forall

parts

of

health

carecontinuum

is·

“right

patient,right

place,righttimewith

right

care

giver”

.《急救護理學》what

is

Triage

?·A

sortingprocessutilizingciriticalthinkinginwhichanexperienced

nurseassessespatientsquickly

upontheirarrivalat

anemergency

setting

to:1.assessanddetermineseverityofpresenting

problems

2.process

patients

into

a

triage

category3.determine

access

to

appropriate

treatment4.effectively

and

efficiently

assign

appropriate

human

healthresources《急救護理學》Avoiding

Triage

as

a

block·T

hetriage

processshould

not

becomeablock

or

significant

delay,but

rather

a

wayof“streaming”patients

to

the

mostappropriate

care

area.《急救護理學》《急救護理學》分診處的設置·

位置：面對急診科大門的明顯處·物品：電話、電腦、平板車、輪椅、血壓計、聽診

器、體溫計及各種表格等·

人員：急診護士，導診員或秘書《急救護理學》急診分診程序Triageprocess《急救護理學》Triageprocess·

Patient'sarrival·

Critical

look-A

airway-B

Breathing-C

Circulation-D

Disability(neurological)《急救護理學》1.A

airway

氣道及頸椎氣道阻塞的原因?氣道阻塞如何處理?保持氣道通暢的方法?《急救護理學》急診護理評估人工氣道分類常見非確定性緊急人工氣道技術●

手法開放氣道：常用提頦和雙手抬頜法。●

口咽和鼻咽通氣管

●

喉

罩常見確定性緊急人工氣道技術●

經(jīng)口氣管插管術●經(jīng)鼻氣管插管術：纖維支氣管鏡引導氣管插管●

氣管切開術《急危重癥護理學》《急救護理學》人工氣道分類通氣導管-

口咽通氣導管-鼻咽通氣導管喉罩氣管插管-經(jīng)口氣管插管-經(jīng)鼻氣管插管氣管切開置管經(jīng)皮穿刺氣管造口置管術環(huán)甲膜穿刺/切開術《急救護理學》急診護理評估2.B

Breathing

呼吸功能呼吸功能評估包括哪些?呼吸功能異常如何處理?《急救護理學》急診護理評估3.C

Circulation

循環(huán)功能循環(huán)功能評估包括哪些?循環(huán)功能異常如何處理?《急救護理學》急診護理評估4.D

Disability

(neurological)

神志狀況：AVUP法AlertVocalPainUnresponsive法5.暴露患者/環(huán)境控制Triageprocess·

Infectioncontrol·

SubjectiveAssessment·

ObjectiveAssessment-Selecting

presentingcomplaint·TheTriageDecision

病情嚴重程度分類系統(tǒng)-CTAS

levels《急救護理學》CTAS

Renewal

Form

2013-2014Belowarethenewinstructionsforaccessingthe

CTAS

materialsfor

Instructors.Ifyou

have

nctupdatedyourCTAS

membershiporNENAfees,youwil

needto

complete

both

tasks

prior

to

gaining

accesstotheCTAS

Instructormaterials.Pleasevisitthemainpageofthecaep.cawebsite

and

logintothe

site

using

the

username

and

password

issuedwith

the

welcome

email.Once

logged

in

pieaseclickonthe"Goto

mydashboard"link

then

on

the

blue

CTAS/Pre-Hospital

CTAS'link

located

in

the

bottom

right.Fromthe

new

pagecickon

eitherCTAS

Instructors

Documents

ENGLISH2013-2014CTAS

InstructorDocuments

FRENCHPre-HospitalCTASInstructorDocumentsIf

youareanAmericanCTAS

Instructor,pleaseclickonthe

USVersion2013-2014

CTAS

link.lfyouexperiencecomplicationswiththeloginprocess,pleasecontact

Gisele

Leger

at

(613)523-3343x

10ormailtoadmin@caep.caCAEPmembersorvisitors

interested

in

leamingmoreaboutCTAS,please

review

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content

options

below.《急救護理學》HOME

LOGINCONTACT

USSEARCH

FAQCAEP

IGraSenAtsGatcnaf

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ansACHU

idesaes

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CJEMADVOCACYRESOURCESRESEARCHRESIDENTS&MED.STUDENTSABOUT

CAEPCAEP

ResourcesExternalLinksEmploymentCTASImplementation

GuidelinesHowto

becomea

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TrainerCTAS

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-

MemberFeedbackCAEPEndorsementH1N1

InfluenzaResourcesCanadian

Triage

And

Acuity

Scale

(CTAS)Home/ResourcesEmergencySeverityIndex,

Version

4:ImplementationHandbook5(least

resourceintensive).The

ESI

is

unique

amongtriage

tools,byincluding

both

acuity

and

resource

needs

in

the

system

of

categorizing

ED

patients.The

ESI

is

a

powerfultoolfor

enhancingpatient

safety

at

triage

as

well

asproviding

casemix

data

to

supportemergency

department

operationaldecisions,quality

initiatives

and

clinical

research.ESI.Now

taking

purchase

orders.ESITraining

ModuleTraining

moduleforemergency

departmentsRecent

PublicationsEmergency

Severity

Index.Version

4:ImplementationHandbook.ESIalgorithmHistoryTrainingPublicationsESIEvaluationAbout

usProducts

ft

servicesWelcome

to

theEmergencySeverityIndex

(ESl)The

Emergency

Severity

Index

(ESI)is

afive-level

tool

for

use

in

emergencydepartment(ED)triage.Experienced

ED

nurses

use

the

ESI

to

rate

patientacuity,from

level

1(most

urgent)to

levelWhat's

new…?The

only

course

developed

and

taught

by

the

creators

of

theDISCLAIMERIWEBMASTERIWEBSITE

FEEDBACKICONTACT

USESIWEB

COURSE2Emergency

Severity

Index(ESI)ATriageToolforEmergencyDepartmentCareVersion4lmplementation

Handbook2012

Edition(6ResuscitationEmergentUrgentLess

UrgentNon

Urgent23復蘇危急緊急次

非緊平收45《急救打“TN加

山

心

高

山

心—LevelIResuscitationsee

patient

immediatelyLevelⅡEmergencywithin

15

minutesLevel

ⅢUrgencywithin

30

minutesLevel

IVLess

Urgencywithin

60

minutesLevel

VNon

Urgencywithin

120

minutes《急救護理學》國

際

“

T

R

I

A

G

E

分

級

范

疇特

征

描

述1危及生命·如果一來到急診科未得到緊急的救治，病人可能死亡。2危及生命或需緊急處理·如果未在到達后的10分鐘內(nèi)得到救治，病人的情況會很嚴重或短時

間內(nèi)惡化而可能危及生命，或致器官功能衰鶴?；颉εR床治療結果將產(chǎn)生重要影響的緊急處理(如溶栓、解毒),需要在病人到達急診科的數(shù)分鐘內(nèi)便開始進行?；颉娜说乐髁x的立場，必須在10分鐘內(nèi)行止痛性處理以減輕極度的疼痛或痛苦

.3可能危及生命或情況緊急如果未在到達后的30分鐘之內(nèi)進行診斷和治療，病情可發(fā)展惡化，甚至危急生命。或·如果未在到達后的30分鐘之內(nèi)進行緊急處理可能會導致預后不良。或·從人道主義的立場，須在30分鐘內(nèi)行止痛性處理以減輕嚴重不適或痛

苦

.4有滑在的危險性低緊急度*如果未在到達后的1小時內(nèi)進行診斷和治療，病情可能惡化或會導致預后不良，或·從人道主義的立場，應在1小時內(nèi)行止痛性處理以減輕不適或痛苦。5非緊急·病人的病情為慢性或較輕.在到達后的2小時內(nèi)進行治療，不會對癥狀和臨床治療結果產(chǎn)生影響.《急危重癥護理學》下面給每一個級別提供一個簡明的特征描述ACUITYLEVELATS

DOOR-TO-DOCTOR

TIMEICTASDOCTORDOOR-TO-TIME2Level

1Level

ILevel

lLevel

IVLevel

VImmediate10

minutes30

minutes60

minutes120

minutesImmediate15

minuteslessthan

30

minuteslessthan

60

minutes120

minutesTable5.ComparisonofAustralianTriageSystem(ATS)andtheCanadianTriageandAcuity

System

(CTAS)Benchmark

Times《急救護理學》>

心跳呼吸停止>

懷疑心肌梗死引起的胸痛>

嚴重心律失常>

中度燒傷>

呼吸道梗阻、呼吸窘迫>

嚴重創(chuàng)傷大出血>

張力性氣胸等>

過敏性休克·Cardiac

arrest·Respiratory

arrest·Major

traumain

shock·Shortnessof

breath

(severerespritarydistress)·Alteredlevel

ofconsciousness(unconscious,GCS3-9)《急危重癥護理學》Level

1-ResuscitationDeterminingthe

CTAS

levelsMore

information

is

needed

to

determine

the

CTAS

levels.·

First

Order

Modifiers·Second

Order

Modifiers-Vital

signs·RespiratoryDistress·HemodynamicStatus·Level

ofConsciousness·Temperature—Other

modifiers·Painscore·Bleeding

disorder·Mechanism

of

injury《急危重癥護理學》—Blood

Glucose

Level-Dehydration

severity

-Blood

PressurePatientsreassessmentguidelines·Level1continuousnursingcare·Level2—every

15

mins·L

evel

3—every

30

mins·

Level4—every60

mins·

Level5—every

120

mins《急危重癥護理學》RoleofTriageNurse1.Assessingpatients2.Communicating

with

the

public3.Communicatingwith

Health

professionals4.Assigningresources5.Initiatingtreatment

protocols/firstaidmeasures

6.Monitoring

and

reassessing7.Paticipating

in

patientflow8.Documenting《急救護理學》《急救護理學》Characteristicsof

theTriageNursewhat

makes

a

good

triage

nurse?·

Personaltraits·

Cognitivecharacteristics·

Behavioralcharacteristics我的強項我的弱項Personal

traits1.2.3.1.2.3.Cognitivecharacteristics1.2.3.1.2.3.Behavioralcharacteristcs1.2.3.1.2.3.《急救護理學》練習：

forpersonal

reflection《急救護理學》·

Personal

traits—Flexibility—Automomy-Good

communication

skills-Assertiveness-Patience-Compassion-Willingness