A practical nurse (PN) is deployed to a community triage site following an external mass casualty incident. Using the adult START (Simple Triage and Rapid Treatment) algorithm, arrange the following clinical assessment steps in the precise chronological order the nurse should perform them. (Place the first action at the top and the final action at the bottom.)
- 1Direct all individuals who are able to walk to move to a designated staging area.
- 2Check for the presence of spontaneous breathing and reposition the airway if necessary.
- 3Count the respiratory rate to determine if it is above or below 30 breaths per minute.
- 4Palpate for a radial pulse and evaluate capillary refill time.
- 5Assess the victim's ability to follow a simple command such as squeezing hands.
Cevap
The correct sequence for adult START triage is to first clear all ambulatory victims, then assess for the presence of spontaneous breathing (opening the airway if absent), evaluate the respiratory rate, assess perfusion via radial pulse or capillary refill, and finally check mental status by issuing a simple command.
The correct order strictly follows the mass casualty disaster triage protocol known as START. The mnemonic RPM (Respirations, Perfusion, Mental Status) applies only after the 'walking wounded' have been evacuated from the immediate assessment zone. Within the respiratory parameter, the presence of an airway and spontaneous breathing must logically be established prior to counting the actual respiratory rate.
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START (Simple Triage and Rapid Treatment) Algorithm