Pediatric emergency medicine trisk 0135 0135
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TABLE 6.6
HIGH-RISK VITAL SIGNS
Age
Respiratory rate
Heart rate
<6 mo
6–12 mo
1–2 yrs
2–8 yrs
>8 yrs
>60
>50
>40
>30
>20
>180
>160
>160
>140
>100
Oxygen saturation <92%; capillary refill <1 second or >3 seconds.
Triage Decision
Information gathered during the aforementioned aspects of the triage process is
synthesized during this stage to provide appropriate triage interventions and
assignment of acuity. The initiation of nurse-led protocols, standing orders or
clinical care pathways in triage can help expedite patient care, improve ED flow,
and positively impact patient/family satisfaction. Such triage interventions are
delineated by unit, hospital, and state protocols. Examples include administration
of analgesia or antipyretics, initiation of NPO status or PO challenge, application
of ice or basic splints, point-of-care testing, EKGs, simple wound care, x-ray
orders, or clinical care pathways. Triage interventions should be agreed upon and
clearly defined in departmental policy and procedure manuals. Isolation needs
should also be addressed during this phase of triage if a patient is
immunocompromised or suspected to have an infectious disease process. Once
appropriate care is provided, the patient acuity should be assigned based upon the
triage classification system utilized in the facility’s ED. As previously mentioned,
this acuity will determine the patient’s priority and appropriate location of care.
Triage Documentation
Patient acuity, chief complaint, and pertinent subjective and objective data
gathered during the triage process should be recorded in an organized fashion in
the medical record, allowing for baseline patient information and triage decisionmaking factors to be shared with all necessary staff. Any triage care intervention
should also be clearly charted. Additional documentation may be required per
hospital or governmental standards. As safe pediatric care requires weight-based
dosing, patients should have their weight obtained and recorded in kilograms.
