Report from Triage Nurse – COPD Nursing Care in ER

00:00 Okay, so now you're gonna get report from the triage nurse.

00:04 See, in an emergency room setting, all the ERs have triage areas.

00:09 That means that's a nurse who's trained to recognize what a patient's going through, what are emergencies and need to be bumped up the priority list to be seen, and who can wait a little bit longer.

00:20 Now, it's a really tough job in ER to be the triage nurse because you're the main contact person and some -- nobody likes to wait particularly when you don't feel good. But that's the job of a triage nurse.

00:33 That's why we break it up into shorter shifts usually in most ER departments.

00:37 You don't do that every day in, day out.

00:39 But her job is to -- her or his job is to assess the patient quickly, find out what the top priorities are, and determine what their prioritization is in being admitted.

00:49 Since Mrs. Taylor was brought in by her daughter, she will see the triage nurse.

00:54 Ambulance admits are a little bit different but she was brought in by a family member so she would check in and meet the triage nurse.

01:02 So let's look at her initial vital signs. Mrs. Taylor's initial vital signs in triage were -- okay, this is where you need to be writing this down.

01:11 Okay, so the initial sat was 86% on room air.

01:16 Hey, that's a number so every time you see a number, you're asking yourself high, low, or normal.

01:21 So initial vital signs when the triage nurse got to this patient were 86% on room air.

01:27 Well, that's obviously too low, right? Her respirations were 32. That's high.

01:34 So when someone has a high respiratory rate and a lower pulse ox, that's a definite sign that they're heading into trouble or are already there.

01:43 Now, pulse ox is 109. That's high. Okay, that's too high for the patient.

01:49 That's not normal. That's another indication that the patient is working really, really hard.

01:54 The blood pressure, that's high too. 168/98.

02:00 Now wait a minute, yes that's high but what's an important question to ask Mrs. Taylor? Right. If we can get a baseline of what her normals are, that will also help us.

02:12 She may or may not know but most patients do. Temperature 37.1 or 98.8.

02:18 That's not really that impressive.

02:20 But she was quickly identified by the triage nurse as respiratory distressed and the triage nurse prioritized Mrs. Taylor for immediate admission to the emergency room.

02:31 So we're gonna get her back.

02:33 Now go back and look at those vital signs as we talk through it, I want you to pause the video and replay in your own mind what do you think most influenced the triage nurse to bump her straight to the top to be admitted? Okay, cool. Welcome back.

02:51 It's really good exercise for you to practice thinking like a nurse in different settings and that's what we're gonna do throughout this case study.

02:59 So I know you saw that wow, she's got some vital signs that are not normal.

03:03 Her respirations are fast, her sat is too low, her heart rate is elevated, blood pressure is up so this is somebody in respiratory distress.

03:11 We know they hit a big priority with being admitted.

03:15 These are things, hopefully, you really highlighted on your notes and you knew that, yeah, this is the indication that said why Mrs. Taylor should be prioritized to be admitted.