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Difficulty: MediumEmergency Response Plan

A nurse is assisting with field triage following a roof collapse at a local warehouse. Using the START (Simple Triage and Rapid Treatment) method, the nurse assesses an adult client who is sitting on the ground. The client has an obvious deformity of the right lower leg and reports severe pain. The client is unable to walk. The respiratory rate is 22 breaths/minute, the radial pulse is strong and regular, and the client correctly follows the command to squeeze the nurse's hand. Which triage category should the nurse assign to this client?

  1. A
    Immediate (Red tag)
  2. Delayed (Yellow tag)Answer
  3. C
    Minimal (Green tag)
  4. D
    Expectant (Black tag)

Answer

The correct answer is Delayed (Yellow tag). Based on the START triage algorithm, this client has stable vital signs and mental status but is unable to walk, which classifies them as needing delayed care.
According to the START (Simple Triage and Rapid Treatment) algorithm for mass casualty events, a client is categorized as Delayed (Yellow tag) if they are unable to walk but have stable respiratory status (rate < 30 breaths/minute), adequate perfusion (radial pulse present or cap refill < 2 seconds), and an intact mental status (able to follow simple commands). Despite having a severe leg injury and severe pain, this client's physiological stability means their definitive treatment can be safely delayed.

Step-by-Step Solution

1
Assess the client's ability to ambulate.
The client is unable to walk due to a leg deformity.
If the client could walk, they would be immediately classified as Minimal (Green tag). Since they cannot, further physiological assessment is required.
2
Assess the client's respiratory status.
The respiratory rate is 22 breaths/minute.
A respiratory rate under 30 breaths/minute indicates adequate ventilation, prompting the nurse to move to the next step of the algorithm. A rate over 30 would immediately result in an Immediate (Red tag).
3
Assess the client's perfusion.
The radial pulse is strong and regular.
The presence of a radial pulse indicates adequate systemic perfusion. Absence of a radial pulse (or capillary refill greater than 2 seconds) would necessitate an Immediate (Red tag).
4
Assess the client's mental status.
The client successfully follows the command to squeeze the nurse's hand.
Because the client can follow commands and has normal respirations and perfusion, they are classified as Delayed (Yellow tag), regardless of the severity of their isolated extremity injury.

Key Concept

START Triage Algorithm
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Topics

Emergency Response Plan

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