Nursing Student
New Grad

04.04 Triage

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Cheat Sheets Mnemonics


  1. Triage
    1. What is triage?
    2. Situations for triage

Nursing Points


  1. What is triage?
    1. Categorization system that establishes severity
    2. Method of Prioritization
  2. ESI Emergency Triage Algorithm
    1. ESI is the algorithm used by emergency rooms to triage
      1. Does the situation require a life-saving, immediate intervention?
      2. Is the situation high risk? Is the patient lethargic or confused? Is the patient in severe distress or pain?
      3. Is the patient’s vital signs in a dangerous range?
      4. How many additional resources are needed?
        1. If 1 or more additional resources are needed, it changes the algorithm.
    2. See the link attached to this lesson for more information
  3. Situations
    1. Emergency Department
      1. Emergent
        1. Needs immediate treatment
        2. Right now
        3. Ex: Trauma, Stroke, MI, Head injuries
      2. Urgent
        1. Needs to be seen in 1-2 hours
        2. Ex: Fever, HTN, Fractures
      3. Non Urgent
        1. Can wait
        2. Stable Patients
        3. Ex: Sprains, minor injuries, cold/virus
    2. Disasters
      1. Survivable Injuries
        1. Immediate threat of death
        2. Stable Patients
      2. Non Survivable Injuries
        1. Dead on arrival or actively dying with non-survivable injuries

Nursing Concepts

  1. Prioritization
  2. Clinical Judgment

Patient Education

  1. Educate patients who are in the ER waiting room  with stable illnesses or minor injuries that there are other patients that have life-threatening emergencies
    1. Be compassionate
    2. Be patient

Reference Links

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Video Transcript

All right. We’re gonna talk about Triage. Now this stuff is pretty cool. I really enjoy trauma and triage, and stuff like that, so we’re gonna talk about this and let you know what you need to know to understand how things are working in a hospital, but we’re gonna go pretty high level with this. There’s some associated links and stuff in here that you can use to help you understand it a little bit better.

But, what is triage? Triage really is nothing more than just a categorization system. It establishes the severity of an illness or injury. It’s really used in an emergency or disaster situations to determine which patients have injury, illness, and what degree of injury or illness they have and how we should then treat that. Now it’s really a method of prioritization for these types of situations.

Now let’s talk now about ESI, or the Emergency Severity Index. This is really an algorithm used by emergency rooms to triage patients. This is really used in day to day life inside the emergency room triage. What it does is it really helps us answer which patients needs to be addressed faster. Does the situation require a life saving immediate intervention? Is the situation a high risk situation? Is the patient lethargic or confused, or is the patient in severe pain or distress? Does the patient have vital signs that are in dangerous zones, so are they massively elevated or massively low, or are the patients signs just up a little bit, down a little bit, or are they normal?

And then how many resources are needed for the patient? The interesting thing here is the higher number equals better for this patient. Okay. If one or more resources are needed it starts to change the algorithm. Now there’s a link in this lesson that shows you how the ESI is calculated, so I’d encourage you to go check that out. Don’t spend too much time with it, but just know that, that’s there. It’s something that’s used to gauge the severity of different patients.

In the Emergency Department they might also say the patient has an emergent need, an urgent need, or non-urgent need. If a patient has an emergent need they need treatment right now. We can’t wait. We must take care of them now. They need immediate treatment. This would be things like trauma, stroke, MI, head injuries. For many of these injuries there’s specific time frames that certain things must be done, okay. For MI and for stroke there’s certain time frames where we must get CT, we must get a needle, we must get medications done within a certain time frame.

Then we have urgent needs. These are patients that need to be seen within one or two hours. The patient might have a fever that’s climbing. They might have hypertension that’s also climbing. They might have fractures. These are issues or situations that we need to address, but we have some time with this. It’s not completely emergent, it’s urgent.

Then we have non-urgent situations. These are stable patients, or patients with minor injuries. Your patient might have a sprain. They might have a minor injury. They might have a cold, or a virus. They’re not comfortable. They have something going on, but we don’t have to address something right now. We have more than a couple hours to deal with it.

Now in disaster situations patients are separated by the survivability of their injury. So, if the patient has a survivable injury we say that they’re in … but they’re in an immediate threat of death, they get this color code of red. It’s an emergent patient. It’s something we must deal with right now. They’re in immediate threat of death. We call them a Code Red. Now if the patient is stable but urgent, something that must be dealt with very soon, they’re a Code Yellow. If the patient is stable then they’re a Code Green. Now in disaster situations they use something a little bit different. They use this color coding system to help identify patients and what their needs are in these situations, so they’re really separated by survivability, whether the patient’s injuries are survivable or non-survivable.

Survivable injuries are separated out by either immediate threat of death, or stable. If the patient is in immediate threat of death then they have emergent needs, something we must deal with absolutely right now. They get a Code Red. If the patient is stable, but they have urgent needs they’re a Code Yellow. If the patient is stable and has no injuries going on, but they’re there and they might have minor needs then that patient is a Code Green.

Then we have our non-survivable injuries. The first one would be dead on arrival. We can’t do anything for this patient. This patient has passed. There’s nothing we can really do. Then you have your actively dying patients. These patients are going to die if nothing is done. Now, we still make all efforts that we can to make these patients comfortable via comfort care, things like morphine. We try to make these patients comfortable, but they are actively dying. Then we have our currently alive patients with non-survivable injuries. These patients are Code Black. Okay. We can’t really do anything for these patients. They’re either dead on arrival, actively dying, or currently alive with non-survivable injuries.

All right guys, so what are the nursing concepts you need to be aware with this? First, we would be prioritization. It’s so important that we understand how patients are triaged both in the emergency room, or in disaster situations. That’s the first nursing concept you would look at. Then clinical judgment. Our job as nurses is to understand what needs to be done now, what needs to be done soon, and what could be held off. These triaging strategies are used to help you know what patients must be seen now and which ones can be held off.
Let’s talk about some of the key points that we just covered here. First would be prioritization. Triage is really a method for categorizing the severity of injuries and focusing on the patients that need to be prioritized first versus later. It’s very situational. It’s used in Emergency Departments as well as in disaster situations. They have different ways of doing that in emergency rooms like the ESI, and then in disaster situations with the color coding. And then it’s done by severity. It’s either emergent, urgent, non-urgent. This is in emergency rooms and they use the ESI as well. And then in disaster settings it’s really done by the survivability of the injury, whether it’s survivable, non-survivable. They assign color codes to these patients.

All right, guys. That’s a quick overview of Triaging. That should help you understand what happens in a hospital, what happens in a disasters, a quick overview of that. Make sure you check out all the links and the different resources with this lesson to help you understand a little bit more. Now go out and be your best selves today. Happy Nursing.

Read more

  • Question 1 of 10

There are 4 pediatric clients sitting in the waiting room of the emergency department. A bed becomes available and the triage nurse knows to take back the client with which of the following first?

  • Question 2 of 10

A nurse is working in triage during a mass casualty event that sent 50 clients to the emergency room for care. According to the principles of triage, which of the following client conditions is correctly matched with its appropriate priority level? Select all that apply.

  • Question 3 of 10

The nurse in the trauma bay is concerned that a client is suffering from a stomach injury related to a gun shot wound. Which of the following signs and symptoms is the nurse observing?

  • Question 4 of 10

A client is brought into the trauma bay after being stabbed in the abdomen with a 12 inch knife. The blade is still present in the client. The client is complaining of severe abdominal pain and is restless. After completing the initial survey, which of the following is the next thing the nurse should do?

  • Question 5 of 10

The nurse is working in the emergency department when an older adult is brought to the ER from a long-term care facility. The staff reports that the client is acting different and has had a fever for a few days. The nurse assesses the client’s temperature and it is 103 F orally. Which labs are important to collect on this client? Select all that apply.

  • Question 6 of 10

A nurse is working in the emergency room when the hospital is notified of a nearby plane crash. Most of the victims will be transported to the hospital. The nurse is working as part of the triage team. Which clients would be the highest priority? Select all that apply.

  • Question 7 of 10

A client presents to the emergency department with complaints of chest pain. What is the priority for the nurse?

  • Question 8 of 10

A nursing student is asking a nurse about prioritization of client needs. The nurse knows that which of the following client symptoms would need to be seen first?

  • Question 9 of 10

A triage nurse takes a call from a client who has been burned while trying to do some electrical wiring. The nurse asks the client for more information. Which data from the client would indicate that they have suffered a 2nd-degree burn?

  • Question 10 of 10

The nurse knows that common mechanisms of injury involved in penetrating trauma include all of the following except which of the following?

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