Understanding Triage and Vital Signs in Healthcare

Triage and vital signs play a crucial role in healthcare settings, especially in hospitals, to assess patients and determine the urgency of their condition before they are seen by a doctor.

What is Triage?

The term “Triage” originates from the French verb “trier”, meaning to separate or select. It is the process of determining the priority of patient treatment based on the severity of their condition. The goal of triage is to identify patients who require immediate, lifesaving treatment while preventing harmful delays.

Key Aspects of Triage:

Conduct an Airway, Breathing, Circulation, Disability (ABCD) assessment to identify emergency and priority signs.
Triage applies to patients of all ages.
Quick evaluation is essential, ideally within 20 seconds.

When Should Triage Take Place?

Immediately upon the patient’s arrival at the hospital.
Before any medical review or procedure is conducted.

Triage Categories:

Emergency Signs: Patients with life-threatening conditions that require immediate care (e.g., obstructed airway, severe difficulty breathing, inadequate circulation, reduced consciousness, or convulsions).
Priority Signs: Patients without emergency signs but with conditions like high fever, severe pain, trauma, or respiratory distress. These patients are treated immediately after emergencies.
The Wait Category: Patients without emergency or priority signs can wait in the queue. The triage nurse should explain the priority system to avoid frustration.

Conditions for Effective Triage:

No detailed history is taken.
Focus is solely on identifying emergency signs.
Quick assessment within 20 seconds.

Vital Signs

Vital signs are essential indicators used to assess a patient’s physiological and psychological condition. They provide critical information about the body’s vital organ functions, particularly the cardiovascular and respiratory systems.

Key Vital Signs:

Temperature (T)
Pulse (P)
Respiratory Rate (R)
Blood Pressure (BP)
Pulse Oximetry (SpO2)

Why Are Vital Signs Important?

Establish baseline values for cardiorespiratory health.
Aid in diagnosis and treatment decisions.
Monitor patient progress and response to medication.
Detect potential side effects of drugs.

When to Measure Vital Signs:

When a patient experiences a change in health status.
Before and after administering medications that affect the respiratory or cardiovascular system.
Before and after surgery or an invasive diagnostic procedure.

Breakdown of Vital Signs:

1. Temperature

Measured using a thermometer.
Sites for measurement: Oral, Rectal, Axillary, Tympanic.
Normal range: 36.0°C – 37.5°C.

2. Pulse

Measures the pressure wave created when the heart contracts and ejects blood into the aorta.
Normal rate: 60-100 beats per minute (bpm).
Tachycardia: Above 100 bpm.
Bradycardia: Below 60 bpm.
Pulse sites: Carotid, Temporal, Brachial, Radial, Femoral.

3. Respiratory Rate

Measures the number of breaths per minute.
Normal range: 12-20 breaths per minute.

4. Pulse Oximetry

Measures arterial oxygen saturation using a non-invasive pulse oximeter.
Normal SpO2 level: 95% or higher.

5. Blood Pressure

Measures the pressure exerted by blood on the walls of blood vessels.
Measured using a sphygmomanometer and stethoscope or an automated BP machine.
Normal range: 120/80 mmHg.
Hypertension: High blood pressure.
Hypotension: Low blood pressure.

Key Components:

Systolic Pressure: The pressure when the heart contracts and pumps blood.
Diastolic Pressure: The pressure when the heart relaxes and refills with blood.

Conclusion

Understanding triage and vital signs is essential for healthcare professionals to ensure timely intervention and appropriate care. Effective triage prevents unnecessary delays, while monitoring vital signs allows for better diagnosis, treatment, and patient monitoring.