Question

Disaster Drill Scenarios You are the nurse responding to an explosion at the Weis Markets. You were shopping and do not have any resources to assist you in caring for the clients. Place the client in the color code you would in a disaster OUTSIDE of the hospital. Label as Black/ expectant, red/ immediate, yellow delayed, green/ walking wounded. Client 1

General Appearance: An older male with chest pain and SOB

LOC: Alert and oriented, able to follow commands

Chief complaint: Crushing chest pain and SOB

Airway and breathing: R 24 and shallow

Circulation: Cap refill less than 2 seconds

Pulse: Present, fast, and irregular

Skin: Warm and diaphoretic

Triage decision:

Client 2

General impression: An adult female c/o abdominal Pain.

LOC: Alert and oriented, following commands

Chief complaint: Abdominal pain with coffee ground emesis

Airway and breathing: R-22, circumoral cyanosis

Circulation: Capillary refill greater than 3 second

Pulse: P-118 and regular

Skin: Pale and cool to touch, positive Grey Tuners sign

Triage decision:

Client 3

General impression: An adult female presents with visible burns on bilateral upper extremities, face, head, and neck.

LOC: Alert and oriented, slow to respond, not following commands

Chief complaint: Burns

Airway and breathing: R-28 and shallow

Circulation: Capillary refill greater than 3 seconds

Pulse: P-120

Skin: Visibly burned

Transport/triage decision:

Client 4

General impression: A young child wandering with a laceration to his forearm. Searching for his mother

LOC: Alert and oriented. Tearful, following commands

Chief complaint: Cut to left forearm 6 cm bleeding profusely

Airway and breathing: R-22

Circulation: Capillary refill less than 2 seconds

Pulse: P-90 and regular

Skin: Warm to touch

Transport/triage decision:

Client 5

General impression: An adult female with an open fracture of a lower extremity.

LOC: Alert and oriented, to self only, unable to follow commands

Chief complaint: Pain of lower left leg.

Airway and breathing: R-22 and regular

Circulation: Capillary refill greater than 4 seconds, bleeding from site

Pulse: P-98 and regular

Skin: Cool and clammy

Triage decision:

Client 6

General impression: An adult female

LOC: Unresponsive

Chief complaint: 3rd degree burns to face, head, and neck

Airway and breathing: R-absent

Circulation: Unable to assess

Pulse: P-absent

Skin: Cool to touch

Triage decision:

Client 7

General impression: An adult male with visible traumatic injuries and cheyne- stokes respirations.

LOC: Unresponsive Chief complaint: Multiple traumatic injuries. Battle sign behind left ear. Raccoon sign.

Airway and breathing: Cheyne- stokes

Circulation: Capillary refill greater than 4 seconds

Pulse: 58 and irregular

Skin: Cool to touch

Triage decision:   

  Client 8

General impression: A male presents with swelling and deformity of right arm.

LOC: Alert and oriented, following commands

Chief complaint: Right arm pain

Airway and breathing: R-22 Circulation:

Capillary refill less than 3 seconds

Pulse: P-98 and regular

Skin: Warm

Transport/triage decision:

Client 9

General impression: An 11 year old with difficulty breathing with a history of asthma no inhaler.

LOC: Alert and oriented, following commands

Chief complaint: SOB and wheezing

Airway and breathing: R-36 with audible wheezing, O2 sat 86%

Circulation: Capillary refill less than 3 seconds

Pulse: P-120

Skin: Diaphoretic

Triage decision:

Client 10

General impression: An adult female with a visible head injury. 3 cm laceration to forehead, bleeding not controlled

LOC: Oriented to person only, does not obey commands

Chief complaint: Headache and dizziness.

Airway and breathing: R-20

Circulation: Capillary refill greater than 3 seconds

Pulse: P-96 and regular

Skin: Warm to touch

Triage decision:

Client 11

General impression: An adult female unable to move lower extremities.

LOC: Alert and oriented, obeys commands, but cannot move

Chief complaint: Suspected spinal cord injury

Airway and breathing: R-22 and regular

Circulation: Capillary refill greater than 4 seconds

Pulse: P-90 and regular

Skin: Warm to touch.

Triage decision:

Client 12

General impression: An adult female with glass impaled into the lower abdomen. Minimal bleeding at site

LOC: Alert and oriented, obeys commands

Chief complaint: Abdominal trauma

Airway and breathing: R-28 and regular

Circulation: Capillary refill greater than 3 seconds

Pulse: P-120 irregular

Skin: Warm to touch

Triage decision:

Answer 1

Answer: Triage is the process of determining the priority of patients treatment by the severity of their condition or likelihood of recovery with and without treatment.This rations patient treatment efficiently When resources are insufficient for all to be treated immediately,influencing the order and priority of emergency treatment,emergency transport,or transport destination for the patient.

Color coding of triage tag

Black - Expectant: Client 6

Red - Immediate : Client 1, 7,3,5,9,10

Yellow- Delayed : Client 11,12,2

Green - Walking: Client 4,8