Triage nursing protocols

Written by heather mckinney
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Triage nursing protocols
A triage nurse assesses a patient's condition, assigns a status code and prioritises treatment. (medical objects image by JASON WINTER from

A triage nurse works in the emergency room and is one of the first contacts a patient makes when she goes in for treatment. His primary function is to determine severity of a patient's illness or injury through an initial assessment. With these details in hand, he is responsible for prioritising treatment accordingly.


The first protocol for a triage nurse is to assess the patient's condition. A nurse begins by taking the basic information about the patient's symptoms that brought her into the emergency room. The triage nurse collects basic medical history including any medications the patient takes, any allergies the patient may have and any medical condition from which the patient suffers, such as a heart condition, diabetes or high blood pressure. The nurse also takes the patient's vital signs, blood pressure, temperature and heart rate.

Treatment Priority

There are five priority levels for patients who enter the Emergency Room. Part of triage nursing protocol is to assign a level to a patient after initial assessment. Code is the most critical level; this is a person experiencing cardiac arrest or whose vital signs crashed. Critical priority is a patient who has stable vital signs, but whose symptoms indicate a life-threatening condition. An urgent priority is a patient whose symptoms are not immediately life-threatening, but who needs to receive care within two hours. Non-urgent disabled triage level is a patient who cannot walk or sit for a long period, four hours is the maximum time frame for treatment at this level. The least severe level is ambulatory; these patients usually are mildly ill and do not need emergency care, but may be there because it is after-hours or they have no medical insurance.

Starting Medical Treatment

After a patient's prioritisation, the nurse may begin treating the patient, depending upon the severity of the illness or injury. The triage nursing protocol calls for nurses to administer first aid when necessary. This may involve bandaging a wound or providing a sling to make a patient more comfortable. If a patient suffers from minor pain or a low-grade fever, the triage nurse may administer medications like aspirin or acetaminophen to relieve these symptoms.

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