Nurses General Nursing


I work mostly in areas of nursing where I dont get much experience say in having to triage on a daily basis and Id like to know how you, in say ER or ICU, triage? What are the principles of triage,is it the ABCs? and/or what other principles guide you? how do you advoid mis- Triage? are there different types of triages?


772 Posts

this is a great juggling act IMO...Definatly learn to glean a lot in that first visual screening....the person screaming at registraion.."l can't breath"....hey, your screaming, ..your breathing....that is a cursory medical screening....what color are they?...and some ppl just have that look of impending doom...actually this is an aquired skill, sometimes you do mis-triage...the chest pain who is stoic and describes their sx's as non-cardiac.......l have to say though, it is the kids that concern me the most.....l have seen them look well and be far from it.....LR


181 Posts

I agree with I.rea. Wherever one has to triage, be it in the ER or prehospital, you really have to get the "feel" from spending time doing it. Of course, certain things set off warning bells ("This is the worst HA of my life." "It feels like someone is standing on my chest.") and some make you question a little more. (" I have this PN in my whatever and they usually give me Fentanyl because I'm allergic to Tordal, Compazine, T3's, Demerol, ect. ect.")

The more time you spend with presenting patients the more you can do a quick exam and tell yourself Big sick vrs Little sick

I sat in triage as an ER tech for 2 months, for 12 hour shifts, while I was attending nursing school...Then, while not yet graduated, I began to help triaging (w/ an RN co-sign, on nights), learning much w/ each and every patient whom I assessed...

Fast forward 8 years, still working ER/urgent care...Triage is the same everywhere: Look at the patient, listen to the patient, and trust your gut...

ER managers, this is how you get good ER nurses...some new grads CAN do well in a busy ER...One day I was a tech, the next day I was a prepared ER nurse in an urban, Phoenix ER...

stepping down off my soapbox...



219 Posts

Many studies and my own practical experience have indicated that triage is so important that it must be done by the most experienced medical personnel available. The triage RN must know not only anatomy and physiology, he/she also has to know appropriate treatments and the resources of the facility. Diagnosis should not be done at the triage point. Therefore DR's asn especially surgeons make for lousy triage.

Airway-Cspine, Breathing, and circulation are first primary assessments. If any of those are not intact and working everything else must stop. In the military those with compromises here are generally expectant. In the civilian world there is no such category. From there the head to toe assessment is done in1 to 2 minutes per patient. If there is no life threatening condition found in the first 60 seconds of assessment the pt is either delayed or minimal.

To do all of this in so short a period requires a lot of experience and a lot of practice. Triage is an ongoing event until the pt is released. Everyone makes mistakes. Hopefully they never result in death of a patient. But sometimes they do. When you make a mistake in triage you try to learn from it, and never repeat the error.

There are a number of classes designed to introduce the concepts and practice of triage. If you have to do this take every class you can. Good luck. Gary

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