Nursing Clinical Practice Guide
Clinical Scenario: You are the first nurse to arrive at the scene of a multi-vehicle collision on the highway. There are about 15 victims with varying injuries. You have a triage pack with colored tags (Red, Yellow, Green, Black).
Nursing Intervention Strategy:1. Scene Safety & Command: First, ensure the scene is safe for you to enter (no fire, live wires, hazardous materials). Verbally identify yourself as a nurse and assume the triage role if no one else has.2. Global Assessment & Call for Help: Yell, "If you can hear me and need help, raise your hand or come to this area!" This instantly identifies the GREEN (Minor/Walking Wounded) patients. Simultaneously, call 911 or activate the facility's disaster plan.3. Systematic START Assessment: Move quickly to non-ambulatory patients. For each:- Airway/Breathing: Open airway (head-tilt/chin-lift). If no spontaneous breathing, tag BLACK. If breathing, count rate. If >30 or irregular/agonal, tag RED.- Circulation: If breathing is adequate, check radial pulse OR capillary refill. If no radial pulse or capillary refill >2 seconds, tag RED.- Mental Status: If perfusion is adequate, give a simple command: "Squeeze my hand." If they cannot follow, tag RED. If they can follow, tag YELLOW.4. Tag & Move On: Place the appropriate color tag on the patient (often around wrist or ankle) and do not stop to provide treatment during primary triage. Your job is to sort everyone first.
Patient Safety and Precautions:- Key Point! In START triage, you do not spend more than 30-60 seconds per patient. Life-saving interventions during triage are limited to opening an airway (with simple maneuver) or controlling major, life-threatening hemorrhage with direct pressure.- Do not attempt CPR or advanced airway management during the initial sort. It consumes time and resources needed to identify other salvageable patients.- Clearly document or communicate the count of patients in each category (e.g., "3 Red, 5 Yellow, 6 Green, 1 Black") to incoming EMS command.
Nursing Procedure & Medication Flow
In the treatment phase (after triage is complete), care is delivered by priority:1. Red Zone: Nurses here manage airways, start two large-bore IVs for fluid resuscitation (e.g., for our burn patient, initiate Parkland formula calculations), control bleeding, and prepare for rapid transport.2. Yellow Zone: Secondary assessment, splinting fractures, dressing wounds, administering analgesics and antibiotics.3. Green Zone: Supervised area for minor care; may assist with simpler tasks.
A Word from Your Senior Nurse
"Disaster triage feels counterintuitive because we are trained to help everyone. In an MCI, your most important skill is rapid, objective decision-making. That burn victim who is still talking to you is in grave danger—their body is fighting to compensate, but they can crash fast. Your quick triage tag ensures they get the fluids and airway support they need before it's too late. Remember the mantra: 'Sort, Tag, and Move On.' On the NCLEX, they are testing your judgment under pressure. Always think: What is the immediate threat to life? Who can be saved if I act now?"