Association between Manchester Triage System discriminators and nursing diagnoses

Franco, Betina; Busin, Lurdes; Chianca, Tânia Couto Machado; Moraes, Vítor Monteiro; Pires, Ananda Ughini Bertoldo; Lucena, Amália de Fátima

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Revista Gaúcha de Enfermagem

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ORIGINAL ARTICLE • Rev. Gaúcha Enferm. 39 • 2018 • https://doi.org/10.1590/1983-1447.2018.2017-0131 copy

Association between Manchester Triage System discriminators and nursing diagnoses

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

OBJECTIVE

To analyze the association between Manchester Triage System flowchart discriminators and nursing diagnoses in adult patients classified as clinical priority I (emergency) and II (very urgent).

METHOD

Cross-sectional study conducted in an emergency department in southern Brazil between April and August 2014. The sample included 219 patients. Data were collected from online patient medical records and data analysis was performed using Fisher's exact test or the chi-square test.

RESULTS

16 discriminators and 14 nursing diagnoses were identified. Associations were found between seven discriminators and five problem-focused nursing diagnoses, including the discriminator Cardiac pain and the diagnosis Acute pain. Three discriminators were associated with four risk nursing diagnoses, among these Acute neurological deficit with the diagnosis Risk of ineffective cerebral tissue perfusion.

CONCLUSION

Significant associations were found between Manchester Triage System discriminators and the nursing diagnoses most frequently established in the emergency department.

Keywords:
Emergency nursing; Triage; Nursing process; Nursing diagnosis; Nursing care; Terminology

Variable	n = 219
Age (years)^* * Mean ± standard deviation	62.3±15.3
Male gender^† † n (%)	110 (50.2)
Educational level^† † n (%) ^‡ ‡ No report of educational level in 84 patients (38,4%).
Incomplete elementary school	69 (31.5)
Complete high school	25 (11.4)
Complete elementary school	21 (9.6)
Illiterates	10 (4.6)
Higher education degree	5 (2.3)
Incomplete high school	3 (1.4)
Incomplete higher education	2 (0.9)
Morbidities^† † n (%)
Systemic hypertension	119 (54.3)
Diabetes mellitus	62 (28.3)
History of ischemic heart disease	44 (20.1)
Neoplasms	43 (19.6)
Chronic obstructive pulmonary disease	35 (16.0)
Smoking	32 (14.6)
Stroke	30 (13.7)

Discriminators	n=219
Cardiac pain	41 (18.7)
Very low SpO₂	32 (14.6)
Inadequate breathing	31 (14.2)
Abnormal pulse	25 (11.4)
Acute neurological deficit	20 (9.1)
Hypoglycemia	13 (5.9)
Shock	12 (5.5)
Altered conscious level	12 (5.5)
Severe pain	10 (4.6)
Currently fitting	9 (4.1)
Vomiting blood	4 (1.8)
Unable to talk in sentences	3 (1.4)
Passing fresh or altered blood per rectum	3 (1.4)
Exhaustion	2 (0.9)
Others	2 (0.9)

Problem-Focused Nursing Diagnoses ^* * Data expressed in n (%).	n=219
Ineffective breathing pattern	62 (28.3)
Acute pain	49 (22.3)
Decreased cardiac output	12 (5.4)
Impaired comfort	12 (5.4)
Unilateral neglect	10 (4.5)
Ineffective tissue perfusion cardiopulmonary	6 (2.7)
Impaired spontaneous ventilation	6 (2.7)
Acute confusion	6 (2.7)
Ineffective airway clearance	3 (1.3)
Chronic pain	3 (1.3)
Deficient fluid volume	3 (1.3)
Impaired gas exchange	2 (0.9)
Imbalanced nutrition: less than body requirements	1 (0.4)
Impaired urinary elimination	1 (0.4)
Risk Nursing Diagnoses ^* * Data expressed in n (%).
Risk for ineffective cerebral tissue perfusion	21 (9.5)
Risk for falls	18 (8.2)
Risk for unstable blood glucose level	11 (5.0)
Risk for bleeding	8 (3.6)
Risk for deficient fluid volume	4 (1.8)
Risk for impaired respiratory dysfunction	3 (1.3)
Risk for imbalanced fluid volume	2 (0.9)
Risk for electrolyte imbalance	1 (0.4)
Risk for infection	1 (0.4)

Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
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[1] Correspondent author:
Amália de F. Lucena. alucena@hcpa.edu.br