Nursing Triage
Nursing triage is the process of quickly assessing and prioritizing patients based on the severity of their condition to ensure the most critically ill or injured receive prompt care
Goals of Nursing Triage
Ensure life-threatening conditions are identified and treated first.
Prevent deterioration in patients with urgent needs.
Manage patient flow during surges or mass casualty events.
Key Nursing Triage Skills
Rapid assessment (ABC – Airway, Breathing, Circulation)
Critical thinking and decision-making
Clear communication (with patients, families, and the healthcare team)
Documentation accuracy
Emotional regulation under pressure
Sample Triage Process
Initial Assessment – Check airway, breathing, circulation, disability (neuro), exposure.
Figure out Triage Category – Based on severity, vital signs, and need for resources.
Document Findings – Time, symptoms, actions taken.
Reassess as Needed – Patient conditions may change while waiting.
Five-Level Emergency Severity Index (ESI)
A commonly used ED triage tool in the U.S., it categorizes patients into 5 levels
ESI 1: Immediate life-saving intervention required
Example: Cardiac arrest, severe trauma
ESI 2: High risk, confused/lethargic, or severe pain/distress
Example: Stroke, chest pain, suicidal patient
ESI 3: Needs multiple resources, stable vital signs
Example: Abdominal pain needing labs and imaging
ESI 4: One resource needed, stable
Example: Simple laceration needing sutures
ESI 5: No resources needed
Example: Prescription refill, minor rash
Color Coding in Triage
Color coding is used in disaster or mass casualty triage to quickly identify patient priority for treatment and transport when resources are limited. It helps first responders and healthcare providers prioritize care based on the severity of injuries.
Standard Triage Color Codes
Red: Immediate: Life-threatening injuries requiring immediate intervention to survive
Example: Severe bleeding, airway obstruction, tension pneumothorax
Yellow: Delayed: Serious but not immediately life-threatening; treatment can be delayed
Example: Fractures, burns without airway involvement, moderate blood loss
Green: Minor: Walking wounded; minor injuries, care can be delayed
Example: Small cuts, abrasions, sprains
Black: Expectant/Deceased: Dead or injuries so severe that survival is unlikely even with care
Example: Massive head trauma, cardiac arrest without response
Mnemonic to Remember:
“RPM 30-2-Can Do” (Used in START Triage)
Respirations > 30/min → Red
Perfusion: Cap refill > 2 sec → Red
Mental status: Can't follow simple commands → Red
Where It’s Used
Natural disasters (earthquakes, hurricanes)
Mass shootings or bombings
Multi-vehicle accidents
Triage tents in overwhelmed emergency departments