protocol for pediatric triage

Specialties Emergency


Iam looking for a flow sheet to be used for a er dept. for our pediatric patients. This is for assessment purposes by R.N.'s



1 Post

Hello all.I am a Canadian E.R nurse who is also looking for a pediatric triage protocol.

We are currently revising our triage system &

I can find little in the area of peds to streamline the process




3 Posts

hi,the ENPC (emergency nursing peds course) has a terrific peds triage standard that should be used by all EDs. CIIAMPPEDDS: C is chief complaint, I is immunizations, I is isolation (has the child been exposed to any communicable diseases), A is allergies, M is medications,P is past medical history, P is parents impression of the child's condition, E is the event surrounding the illnes or injury, D is diet, D is diapers (voids) and S is signs and symptoms. You should take this course if you are dealing with the little guys in your ED. smiles

Specializes in MED SURG,ICCU,PEDS,ER.

I am a nurse in the emergency room in a small hospital.i just developed a pediatric fall assessment.i am looking for for one for pediatric abdominal pain.pediatric nausea and vomiting,and respiratory.if anyone has any idea i would really appreciate it

Specializes in MED SURG,ICCU,PEDS,ER.

I have a pediatric fall assessment that i developed for my er.i am also looking for assessment tools for pediatric abdominal pain,nausea and vomiting,and respiratory problems

hi i need er web sites


237 Posts

Specializes in emergency nursing-ENPC, CATN, CEN.


90 Posts

Specializes in Emergency.

we don't have a specific flow sheet in our ER for peds triage, but these are the main points i go for when i am triaging the little ones:

-chief complaint

-vs (and remember rule of 60's....HR no less than 60, RR no greater, and SBP no lower than 60....applies to any age pedi (unless baby is crying and for some reason hyperventilating)

-fontanels...are they depressed or swollen?

-is the baby tracking and/or acting appropriately for age

-still having wet and dirty diapers


-mucous membranes dry or moist

-YOU MUST LOOK AT THE BELLY in cases of sob....check for retractions and nasal flaring....can you hear stridor, etc.

-remember that babies are obligate nose breathers, so if they have rhinorrhea or congestion it may be diff for them and they may need suctioning

remember kids and babies who don't respond to you touching them are not doing well.


28 Posts

Specializes in Pediatric Emergency Medicine/Trauma.

Another possible triage guide is SAMPLE:




Past Medical History

Last Meal/Last Diaper


Other ideas are the PAT (pediatric assessment triangle) which is used before you lay hands on the patients. It involves visualizing the Airway, Breathing, and Circulation.

Use the ENPC or PALS resources for ideas. They have excellent ideas.

This topic is now closed to further replies.

By using the site, you agree with our Policies. X