Prepared by :

Salwa Maghrabi
Teacher assistant
Nursing Department

 Definition of triage .

The personal abilities that are essential to be

an effective triage nurse

Daily triage in hospital setting .
Hospital triage system :
Emergent category .
Urgent category.
Nonurgent category

 Triage process :

The gathered information at point of triage .

The initial assessment at point of triage .

Identify the triage .

Count the characteristics to be an effective triage
nurse .
Mention the purpose of daily triage in hospital
setting .
List and differentiate between the categories of
hospital triage system.
Understand the triage process .

It is the process which places the right patient in

the right place at the right time to receive the
right level of care.
Accurate triage allow the nurse to do the
greatest good for the greatest number of
afflicted .

Clinically experience .
Good judgment and leadership .
Calm and cool under stress.
Decisive .
Knowledgeable of available
resource .

Sense of humor .
Creative problem solver .
Availability .
Experienced and knowledgeable regarding
anticipated casualties .

Nurses perform daily triage on a routine bases every

day in the emergency department .

The purpose :
Is to identify those patient who have the highest
degree of compromise for the purpose of providing
rapid care to the sickest patient first .

Hospital Triage System

Emergent

Urgent

Nonurgent

Definition

Time needed

Example

Those that are

life threatening
, but likely to
be amenable
to rapid
intervention
that does not
require an
inordinate
amount of
resources .

requires treatment
immediately or
within 15 to 30
minutes .

Cardiac arrest .
Airway obstructions .
Hemorrhage with shock .
Complicated delivery.
Seizure
Asthma
A cute bleeding or acute
pain .
Depressed level of
consciousness.

I) Emergent Categories

Definition

Time needed

Example

Those conditions
that are serious
and if not treated
in timely manner ,
are likely to
deteriorate to
become critical .

serious illness or
injury that must be
attended to, but
wait of up to 2
hours

Complex long bone

fracture .
Bleeding controlled
with a pressure
dressing.
A cute psychiatric
problem
High fever with other
vital signs stable

II) Urgent Categories

Definition
conditions that can
wait without
likelihood of
deterioration .

Time needed

Example

conditions that can wait more than 2

hours.
-

Minor laceration
which require
sutures.
Minor joint trauma
which requires an Xray for diagnosis .
Request for
medication refills.
Chronic conditions
that are stable Such
as preexisting skin
rash

III) Nonurgent Categories

1- Gathering information at point of triage .

2- Perform initial assessment ( assessment sheet ) at point
of triage .

The goal of triage process :

to gather sufficient data for

determining acuity, identify
immediate needs, and establish
a rapport with the patient and family.

Triage process should be completed within 5 minutes.

1- THE GATHERED INFORMATION AT TRIAGE

POINT
Name
Age
Gender
Chief complain
History of present illness
Mechanism of injury
Past medical or surgical history
Allergies to food or medications .
Current medications

1- THE GATHERED INFORMATION AT POINT

OF TRIAGE CONT
Date of last tetanus immunization
Last menstrual period (for female from age of 11 to 60).
Vital signs : temperature , pulse ,blood pressure ,
respiratory rate.
Skin vital signs : temperature , color , moisture , level of
consciousness.

1- THE GATHERED INFORMATION

OF TRIAGE CONT

AT POINT

Visual inspection for deformities, laceration, bruising ,

rashes , etc .
Height and weight.
Mode of arrival.
Private medical provider .

2- The initial assessment

( assessment sheet )at the
Point of Triage