Table Of ContentFast Facts for the Triage Nurse
An Orientation and Care Guide in a Nutshell
Lynn Sayre Visser, MSN, BS, RN, CEN, CPEN, CLNC
Fast Facts
Anna Sivo Montejano, MSN Ed, RN, CEN
Valerie Aarne Grossman, BSN, RN, MALS
for the
This is a concise, user-friendly orientation guide and reference for new and seasoned
nurses, paramedics, preceptors, educators, management teams, and anyone else
working in the triage environment. It offers guidelines covering key processes and
practices triage nurses use daily. Chapters adres core elements of triage such as Triage
patient point of entry, acuity scales, and “red-fag” patient presentations and how to
handle them; coordination and communication with other health care team members;
and documentation.
The bok ofers practical information on triage for emergency department and urgent Nurse
care settings, with useful tips for both triage orientees and preceptors. It addresses
care considerations for specialized populations including geriatric and pediatric
patients. The text supplies essential information on teaching and learning principles
and the fostering of critical thinking skills, and covers such topics as compassion
fatigue, customer service, legal concerns, core measures, and patient and staf safety. An
Trends in triage nursing such as electronic medical record considerations, provider in
triage, and advanced triage protocols are included. Information is organized in brief,
buleted “bites” for knowledge at a glance, and Fast Facts in a Nutshel boxes reinforce Orientation
key concepts.
Key Features and Care
• P rovides essential guidance for key procedures and protocols in an easy-to-read,
easy-to-access format Guide
• O ffers practical triage information with a focus on emergency department and
urgent care settings in a
• F ocuses on processes, critical thinking, and the legal aspects of triage
• I ncludes care considerations for specifc patient populations Nutshell
• I ncorporates advice from seasoned emergency department nurses and
triage educators
ISBN 978-0-8261-2265-0
Lynn Sayre Visser · Anna Sivo Montejano
Valerie Aarne Grossman
11 W. 42nd Street
New York, NY 10036-8002 9 780826 122650
www.springerpub.com
Visser · Montejano · Grossman Fast Facts for the Triage Nurse
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Visser_22667_PTR_00_i-xx_FM_4-21-15.indd i 21/04/15 4:33 pm
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Visit www.springerpub.com to order.
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FAST FACTS FOR THE
TRIAGE NURSE
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L ynn Sayre Visser, MSN, BS, RN, CEN, CPEN, CLNC, is a registered
nurse with more than two decades of experience, including work in
pre-h ospital care, emergency department (ED), intensive care unit, post-
anesthesia recovery, and organ procurement settings. She is a gifted tri-
age educator and has been instrumental in a number of front-end process
i mprovement projects including the implementation of a medical pro-
vider in the triage area. Mrs. Visser’s involvement in the advancement
of triage education, triage practice, and quality patient care earned her,
along with Mrs. M ontejano, a nomination for the Emergency Nurses
A ssociation Team Award. Her professional scholarship includes 20 years
of membership in Sigma Theta Tau Nursing Society, along with contri-
butions to journal articles, book chapters, blogs, and learning modules,
both as an author and as a reviewer. She co-authored “What is a Triage
Nurse?” published in the J ournal of Emergency Nursing and is the author of
“On the Other Side of the Rails” in the Journal of Radiology Nursing. Her
involvement with the Emergency Nurses Association includes the honors
of being the 2011 national conference blogger, an EMINENCE program
mentee, two-time academic scholarship recipient, and a conference poster
presenter.
A nna Sivo Montejano, MSN Ed, RN, CEN, has 30 years of experience in
emergency nursing and triage education. She has taught nursing theory
and aided the professional development of nurses as a preceptor, men-
tor, and clinical instructor. She has been a certified emergency nurse for
more than 25 years. Her ED contributions include work as a staff nurse,
primary preceptor, and assistant nurse manager, as well as in educational
development. Mrs. Montejano has worked to improve the quality and ef-
ficiency of patient care through projects such as the change process of
rapid medical screenings and rapid triage assessments, as a project man-
ager for a major ED expansion, and as an advanced cardiac life support
instructor. She co-authored “What Is a Triage Nurse?” published in the
Journal of Emergency Nursing. She is the recipient, along with Mrs. Visser,
of a nomination for the Emergency Nurses Association Team Award for
her involvement with improvements in triage processes. She received her
master’s degree in nursing with a focus on education from the University
of Phoenix, and her bachelor of science in nursing from C alifornia State
University, Fresno.
V alerie Aarne Grossman BSN, RN, MALS, is a registered nurse with
more than three decades of diverse nursing experience, including di-
rect patient care, hospital leadership, professional service, and writing
for publication. She has worked in a variety of settings, including ED,
telephone triage, radiology, and administration. She has volunteered her
service to such groups as the Emergency Nurses Association, the Associa-
tion of Radiology and Imaging Nurses, RAD-AID.org, and the National
Certification Corporation, as well as serving on the Research Subject Re-
view Board at the University of Rochester, the New York State Board for
Nursing, and SCORE Board (Stakeholders for Care in Oncology and Re-
search for the Elderly). She serves on the editorial boards for the Journal
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of H ospital Administration and the Journal of R adiology Nursing, as well as
the international advisory board for the journal Nurse Education Today.
She is the author of numerous peer-reviewed journal articles, chapters,
and books, including the Quick Reference to Triage and Emergency Nursing:
5 Tier Triage.
C ontributors
S helley Cohen, MSN, RN, CEN D eb Jeffries, MSN Ed, RN-BC,
E ducator/Consultant CEN, CPEN
H ealth Resources Unlimited C linical Education Specialist
Staff Nurse B anner Desert Medical Center
W illiamson Medical Center Emergency Department
Franklin, Tennessee C ardon Children’s Medical
Center Emergency
D awn Friedly Gray, MSN, RN,
Department
CEN, CCRN
M esa, Arizona
C linical Coordinator
E mergency Department R ebecca S. McNair, RN, CEN
P aoli Hospital P resident/Founder
P aoli, Pennsylvania T riage First, Inc.
F airview, North Carolina
Reneé Semonin Holleran,
PhD, FNP-BC, CEN, CCRN P olly Gerber Zimmermann, MS,
(alumnus), CFRN and CTRN MBA, RN, CEN, FAEN
(retired), FAEN, Former A ssociate Professor
Editor-in-Chief of the H arry S Truman College
Journal of Emergency Nursing C hicago, Illinois
(2006–2013)
N urse Practitioner
A lta View Senior Clinic
H ope Free Clinic
S alt Lake City, Utah
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Visser_22667_PTR_00_i-xx_FM_4-21-15.indd vi 21/04/15 4:33 pm
FAST FACTS FOR THE
TRIAGE NURSE
An Orientation and Care Guide
in a Nutshell
Lynn Sayre Visser, MSN, BS, RN, CEN,
CPEN, CLNC
Anna Sivo Montejano, MSN Ed, RN, CEN
Valerie Aarne Grossman, BSN, RN, MALS
Visser_22667_PTR_00_i-xx_FM_4-21-15.indd vi 21/04/15 4:33 pm
C opyright © 2015 Springer Publishing Company, LLC
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T o triage nurses everywhere.
F ew people can understand what you encounter each shift . . . the
overwhelming and unpredictable influx of patients, the sights and sounds of
distress, the stories that simply do not make sense . . . yet you professionally
balance the chaos with flawless precision, making split-second decisions
in the best interest of each patient. Your selfless acts, gentle hands, and
compassionate hearts touch the lives of many. Your commitment to excellence
is deserving of a book dedicated to you.
Visser_22667_PTR_00_i-xx_FM_4-21-15.indd ix 21/04/15 4:33 pm
