Triage
Triage is the process of sorting and prioritizing patients based on the severity and urgency of their condition to determine the order in which they receive care. In nursing, triage is an RN-level function, but LPNs should understand triage principles for prioritization questions on the NCLEX-PN.
Exam Tip
LPNs do NOT independently triage (RN function). For prioritization: ABCs first, then Maslow's. Acute/unstable before chronic/stable. Actual problems before "Risk for" problems. In disaster triage (START), red = immediate, black = expectant/deceased. See the most critical patient FIRST.
What Is Triage?
Triage is a systematic process of rapidly evaluating and categorizing patients to determine who needs immediate care and who can safely wait. The word comes from the French "trier," meaning to sort. Triage is used in emergency departments, disaster situations, and telephone nursing to allocate limited resources effectively.
Emergency Department Triage Levels (ESI)
The Emergency Severity Index (ESI) is the most common triage system in U.S. emergency departments:
| ESI Level | Severity | Response Time | Examples |
|---|---|---|---|
| 1 - Resuscitation | Life-threatening, immediate intervention | Immediate | Cardiac arrest, severe trauma, respiratory failure |
| 2 - Emergent | High risk, severe pain/distress | Within 10 minutes | Chest pain, stroke symptoms, severe asthma |
| 3 - Urgent | Two or more resources needed | Within 30-60 minutes | Abdominal pain, fractures, moderate asthma |
| 4 - Less Urgent | One resource expected | Within 1-2 hours | Simple laceration, earache, urinary symptoms |
| 5 - Non-Urgent | No resources expected | When available | Cold symptoms, prescription refill, minor rash |
Disaster Triage (START System)
In mass casualty incidents, the START (Simple Triage and Rapid Treatment) system uses color-coded tags:
| Color | Category | Description |
|---|---|---|
| Red | Immediate | Life-threatening but survivable with immediate treatment |
| Yellow | Delayed | Serious but can wait for treatment |
| Green | Minor | "Walking wounded"; can wait for treatment |
| Black | Expectant/Deceased | Dead or injuries incompatible with survival |
Nursing Prioritization Principles
| Principle | Application |
|---|---|
| ABCs | Airway > Breathing > Circulation always first |
| Maslow's Hierarchy | Physiological > Safety > Psychosocial |
| Acute vs. Chronic | Acute/unstable patients before chronic/stable |
| Actual vs. Potential | Actual problems before potential (risk for) problems |
| Unexpected vs. Expected | New/unexpected findings before expected findings |
LPN Role in Triage
- LPNs do NOT independently triage patients (this is an RN function)
- LPNs should understand triage principles for prioritization
- LPNs report changes in patient condition to the RN for re-triage
- LPNs may collect vital signs and data to support triage decisions
Exam Alert
While LPNs do not perform triage independently, prioritization questions on the NCLEX-PN use triage principles. Use ABCs and Maslow's to determine which patient to see first. Always prioritize acute, unstable patients over chronic, stable ones. Actual problems take priority over potential (risk for) problems.
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Related Terms
Maslow's Hierarchy of Needs
Maslow's Hierarchy of Needs is a motivational theory organized as a five-level pyramid, used in nursing to prioritize patient care. From bottom to top: physiological needs, safety and security, love and belonging, self-esteem, and self-actualization. Lower-level needs must be met before addressing higher-level needs.
Nursing Process
The nursing process is a systematic, five-step problem-solving framework used by nurses to provide patient-centered care: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). It is the foundation of all nursing practice and the organizing framework for the NCLEX.
Clinical Judgment
Clinical judgment is the process by which nurses observe, interpret, respond to, and reflect on patient data to make informed decisions about patient care. The NCSBN Clinical Judgment Measurement Model (NCJMM) is the framework used on the NCLEX to evaluate this competency.
Vital Signs
Vital signs are the fundamental measurements of basic body functions: temperature, pulse (heart rate), respirations (breathing rate), blood pressure, and pain (often called the "5th vital sign"). They provide critical data about a patient's physiological status and are assessed by all levels of nursing staff.
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