TRIAGING PROCESS
The triaging process for nurses is a systematic way to assess and
prioritize patients based on the severity of their condition. This process is
essential in emergency departments, urgent care, and other healthcare
settings to ensure that critically ill or injured patients receive care firs
Procedure for triaging
1. Introduction.
Introduce self to the patient explain the process or procedure to
the patient.
Ensure the patient is seated comfortably on a seat where they
can comfortably rest their left arm when taking vitals more so
blood pressure.
1. Initial Assessment
Quick Observation: Assess the patient's general appearance,
breathing, and level of consciousness.
Chief Complaint: Ask the patient why they are seeking medical
attention.
Vital Signs: Measure temperature, pulse, respiratory rate, blood
pressure, and oxygen saturation (SpO₂).
Vital Signs in the Triage Process
Vital signs are essential in assessing a patient's overall condition and
determining the urgency of care. Nurses use these measurements to
identify life-threatening conditions, monitor trends, and guide clinical
decisions. They are as follows:
A. Temperature (T°)
Normal Range
Oral: 36.5°C – 37.5°C
Rectal: 37.0°C – 37.5°C (most accurate for core body temperature)
Axillary: 36.0°C – 37.0°C
Tympanic (ear): 36.5°C – 37.5°C
Abnormal Values & Causes
Hyperthermia (Fever) > 38.0°C
o Infection (bacterial or viral)
1
, o Heatstroke
o Inflammatory conditions (e.g., autoimmune diseases)
Hypothermia < 35.0°C
o Exposure to cold
o Shock
o Metabolic disorders
📌 High fever (≥ 39.5°C) with altered mental status, seizure, or severe
infection requires urgent intervention.
B. Heart Rate (Pulse)
Normal Ranges (beats per minute, BPM)
Adults: 60 – 100 BPM
Children (1-10 years): 70 – 120 BPM
Infants (<1 year): 100 – 160 BPM
Abnormal Values & Causes
Tachycardia (>100 BPM in adults)
o Fever, dehydration
o Pain, anxiety, stress
o Hypoxia (low oxygen)
o Shock, sepsis
o Cardiac arrhythmias (e.g., atrial fibrillation)
Bradycardia (<60 BPM in adults, unless athlete)
o Hypothermia
o Heart block or conduction issues
o Drug effects (beta-blockers, opioids)
o Increased intracranial pressure
📌 Pulse should be checked for rate, rhythm (regular/irregular), and strength
(weak/thready or strong/bounding).
C. Respiratory Rate (RR)
Normal Ranges (breaths per minute)
Adults: 12 – 20
Children (1-10 years): 15 – 30
2
The triaging process for nurses is a systematic way to assess and
prioritize patients based on the severity of their condition. This process is
essential in emergency departments, urgent care, and other healthcare
settings to ensure that critically ill or injured patients receive care firs
Procedure for triaging
1. Introduction.
Introduce self to the patient explain the process or procedure to
the patient.
Ensure the patient is seated comfortably on a seat where they
can comfortably rest their left arm when taking vitals more so
blood pressure.
1. Initial Assessment
Quick Observation: Assess the patient's general appearance,
breathing, and level of consciousness.
Chief Complaint: Ask the patient why they are seeking medical
attention.
Vital Signs: Measure temperature, pulse, respiratory rate, blood
pressure, and oxygen saturation (SpO₂).
Vital Signs in the Triage Process
Vital signs are essential in assessing a patient's overall condition and
determining the urgency of care. Nurses use these measurements to
identify life-threatening conditions, monitor trends, and guide clinical
decisions. They are as follows:
A. Temperature (T°)
Normal Range
Oral: 36.5°C – 37.5°C
Rectal: 37.0°C – 37.5°C (most accurate for core body temperature)
Axillary: 36.0°C – 37.0°C
Tympanic (ear): 36.5°C – 37.5°C
Abnormal Values & Causes
Hyperthermia (Fever) > 38.0°C
o Infection (bacterial or viral)
1
, o Heatstroke
o Inflammatory conditions (e.g., autoimmune diseases)
Hypothermia < 35.0°C
o Exposure to cold
o Shock
o Metabolic disorders
📌 High fever (≥ 39.5°C) with altered mental status, seizure, or severe
infection requires urgent intervention.
B. Heart Rate (Pulse)
Normal Ranges (beats per minute, BPM)
Adults: 60 – 100 BPM
Children (1-10 years): 70 – 120 BPM
Infants (<1 year): 100 – 160 BPM
Abnormal Values & Causes
Tachycardia (>100 BPM in adults)
o Fever, dehydration
o Pain, anxiety, stress
o Hypoxia (low oxygen)
o Shock, sepsis
o Cardiac arrhythmias (e.g., atrial fibrillation)
Bradycardia (<60 BPM in adults, unless athlete)
o Hypothermia
o Heart block or conduction issues
o Drug effects (beta-blockers, opioids)
o Increased intracranial pressure
📌 Pulse should be checked for rate, rhythm (regular/irregular), and strength
(weak/thready or strong/bounding).
C. Respiratory Rate (RR)
Normal Ranges (breaths per minute)
Adults: 12 – 20
Children (1-10 years): 15 – 30
2
