Triage decision

Specialties Emergency


Ok here goes, what category would you assign an asthmatic w/

02 sats = 97% RA, mild resp. distress, w/ slight access. muscle use

and widespread soft wheezes?

Pt. Hx - Admissions: 13, over the previous yr 3X, no previous ICU

admission. Symptoms began w/URTI (05/10),

pt. presents to ER 05/12,

4:30am, states that albuterol nebs have been required q. hr since

approx. 12am, PEFR at 250L/min, PB = 450L/min.

Other vitals, temp 38.6C, BP 110/60, RR 24 and PR 115

I triaged this pt. as level 4/5 - pt. did deteriorate during tx (slightly) and was

admitted (ward admission). When being evaluated by resp. in addition

to frequent nebs, was also started on Amoxicillin & zithromax

+ hydrocort. 250mg (did already have 50mg


Here's why I question myself, I had triaged 3 pts - 2 asthmatics and

1 vomiting.

I triaged the pt. w/the vomiting (temp 38C, bp. 105/55, signs of

dehydration present) as level 3/5. Pt is dc'd after approx. 3 1/2hrs of

treatment maxalon, oral potassium & X2 IV saline

Then we get another pt. w/asthma (26y/o m), 02 sats 98% RA, temp 38.4C,

PR 109, RR 22, and moist cough, also w/mild resp. distress, w/ slight access. muscle

use, but on ausculation, wheeze is clearly A LOT louder (in lower lobes only)than in

the other pt. w/asthma (19y/o f) - who had soft wheezes on ausculation, however, was

widespread. I triaged the 26 y/o pt. as level 3 also.

The 26 y/o is dc'd after 60mg pred, and 4 nebs - 3 of albuterol, 1 of

albuterol/atrovent, (CXR is clear). PEFR initially was 300 (pb 500),

after nebs increased to 480, temp down, 37.7C at dc.

19y/o, when called through, still w/the soft wheeze & widespread (dry cough,

another nurse said pt. had 'tight/wheezy cough'), all

other vitals unchanged, but temp increased at 38.9C. On cont. nebs for

1st hr, then q.1-2hrs after that.

Resp. admitted pt. due to 'sluggish' response to treatment, and also said

given the pt. was febrile increased need for admission. CXR showed

right upper lobe consolidation (didn't hear any crackling in right

upper lobe - RT did though!). PEFR had not gone above 300 at all,

highest obtained was 290. Pt. was admitted to resp ward as HD pt - I

had triaged this pt. as level 4!

Maybe what got was the pt. having 02 sat of 97% RA(at one stage came up

to 100% RA!) most of the time was around 97% though. I thought if this pt.

had good 02 sats then she'd be right to wait a while.

It was my first shift doing triage, and I was just wondering, perhaps

I missed something. Maybe could have done something differently? It

did seem to me resp. were treating this pt. as though the pt. was a

lot more severe than I anticipated. I know I shouldn't question myself, but

it sure makes it hard when some of your colleagues do (--> & did!!)

Thanks in advance,


gwenith, BSN, RN

3,755 Posts

Specializes in ICU.

Best bet is to speak to the doctor admiting - it may be something you wuoldn't have been expected to pick up! Patient assessment if all experiential learning in other words the knowledge comes up through your boots and the only way to get it to rise faster is ask, talk and question. If you do it right not only will the doc not mind but may be even flattered! (AH ME we use every trick in the book!)

Sarah, RNBScN

477 Posts

I think you did a fine job. Remember, you can always bump a pt. up in triage if the condition warrants it.

I hope your colleagues are there for you, especially in this new role. They should be offering assistance and advice if you seek it out. Constructive critique's will go a long way...ignore anyones negativity.

Also, if this is a new role for did they orientate you? Did you do a triage course inservice?

Did they offer to buddy you with a senior nurse re: triage duties?

Remember to go with your "gut" instinct and don't ever feel that you cannot ask for assistance. It is the NURSE who never asks makes you feel UNEASY.

Good luck.


566 Posts

Specializes in ER, Hospice, CCU, PCU.

We use the 1-5 triage system recommended by the ENA. Part of the algorhythm includes looking at vital signs. In an adult patient a pulse rate >100 and resp. rate >24 makes the patient a #2. Should be seen within 15-20 minutes of arrival.

Asthmatic patients can turn bad on a dime. O2 sats seldom tell an accurate story since they measure only o2 and not co2. Also please be careful in assuming that the more (louder) the wheezes are the sicker the patient. An asthmatic in trouble may have severely decreased air movement meaning you may hear only faint (or no) wheezing. Look at the whole picture including how the patient presents. Abnormal vital signs and use of assess. muscles should be a red flag.

The fact that you are questioning yourself is a great sign. It takes time and experience to learn to quickly triage someone. If your facility is using the triage system suggested by the ENA ask your educator for a copy of the algorhythm. It will help alot. After over 20 years in Emergency Medicine I still refer to it at times. And even after 20 years in ER I still have triaged patients as #4's who ended up being monitored admissions. None of us are perfect, what is important is that we continue to learn from our experiences, both good and bad.

Just want to say thanks for the replies.

Have spoke to a few other nurses about the situation. Learnt a few good things in the process.

One senior nurse really did emphasize "not to rely on 02 sats too much" - said some can sound 'as tight as a drum' and yet can have 02 sats >95% RA.

Quite discouraging, I start my new job in Aust. on a resp. ward of all things! (in June).



3 Posts

Triage is not about predicting who will be admitted and who won't be, it is about prioritising who needs care most at the time you triage them. It pays to be very careful with asthmatics as they can deteriorate quickly and often present late in their illness after trying everything at home. Peak flow is a better guide to severity than oxygen sats. When I first started triaginf and even now I would be very wary of giving any ashmatic lower than a category 3.



canoehead, BSN, RN

6,856 Posts

Specializes in ER.

I think you did fine, some suggestions though...ask them when their last neb was- if it was 15min ago gives you a different picture than if it was 2h ago, and that info along with how often they have been getting nebs at home will give you an idea of how long they can wait.

Make sure you are familiar with the asthmatic that has only a few wheezes because they aren't moving any air, as opposed to scattered wheezes and doing OK. It is easy to think they are less acute when you don't hear the wheezes, and if you listen closely you don't hear any air entry either. :(

At the Emergency Department where I work we look at symptom

classification of our asthmatics at triage. This includes peak flow as well as

the respiratory assessment. SpO2 does not play a role in the symptom

classification, although we include it with vital signs.

The patient you speak of would fall into the Moderate acuity, wheezes, partial

sentences, mild retractions, peak flow 55% of her personal best. My concern is

that she is at this moderate acuity in spite of receiving hourly nebs so I

might bump her into the severe category, especially since she is only at 55%

(severe is


We have standing triage orders to obtain a peak flow and initiate a breathing

treatment at triage if we can't get them back to a room right away. Sometimes

this helps us make a decision on getting the patient back sooner if they don't

respond to that treatment.

Your other asthmatic patient would also have fallen in the moderate acuity

category but from your descriptions, the first asthmatic appeared to be more

toxic - multiple previous ED visits, recent URI with fever, mild wheezes which could be more indicative of diminished breath sounds

or a silent chest, putting her into a severe category.

As far as the vomiting patient, it is always hard to sit a patient vomiting

into a bucket back in the waiting room, but I always try to look at my ABCs

with every patient - airway and breathing difiiculties are usually of greater


I applaud you for seeking feedback. It shows that you are improving your

critical thinking skills, something most nurses at 18 months of practice are

still struggling with. Triage is a difficult thing to do, especially for new

nurses. Oh, and never trust an asthmatic w/a quiet chest


Interesting discussion. I have come across a lot of nurses who ignore the asthmatic with the quiet chest.


sorry fo entering a bit late into this disscussion I would have triaged all

apart from the first one the same but for the first one I would have give a 2/5

for this presentation due to the History, The use of charts is a great thing if

used with experince and when to know the chart is wrong. But it is experince

that is learnt through work and learning when to deviate from protocols. HTH. Forgive me, but what does HD stand for Tracey?

i beg to difer tramajunkie.Given the hx (making her fairly toxic) esp. 3 admits in the past year.Given the pt has had no previous ICU admits i would be confidant the pt would stay pretty much stable for longer (hence the 3/5 triage category i would give) w/o needing to assign the pt a 2/5 alex

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