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Pediatric Blood Pressure Triage Guide

This document is a triage form used in a hospital to assess and prioritize patients. It collects information such as name, age, symptoms and vital signs. Patients are assessed and assigned a triage priority level of red, yellow or green depending on whether they show emergency signs, priority signs or are non-urgent. It also provides a TEWS scoring system to further evaluate priority level yellow and green patients based on parameters like mobility, respiration and temperature. The form is used to determine the order patients should be seen in and whether they require emergency treatment or monitoring.

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Stephen Musonda
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55 views1 page

Pediatric Blood Pressure Triage Guide

This document is a triage form used in a hospital to assess and prioritize patients. It collects information such as name, age, symptoms and vital signs. Patients are assessed and assigned a triage priority level of red, yellow or green depending on whether they show emergency signs, priority signs or are non-urgent. It also provides a TEWS scoring system to further evaluate priority level yellow and green patients based on parameters like mobility, respiration and temperature. The form is used to determine the order patients should be seen in and whether they require emergency treatment or monitoring.

Uploaded by

Stephen Musonda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

MINISTRY OF HEALTH

HOSPITAL: _____________________________________________
TRIAGE FORM

Name:……………………………...……………. Age:…….. Sex:…………Weight:.…..kg Length:…………cm OR Height:…….cm Temp:…….. Heart Rate:……. Date:…..…/……./……..

Resps…………………… Blood Pressure:……../…….. mm Hg (Normal, Low, High) O2Sats:…..….% (Normal 92-100%) Capillary refill: _______secs Normal <3secs

TRIAGE Emergency signs [A B C (3) D] Circle appropriately Airway Breathing Circulation Convulsions Coma Dehydration (If there are
emergency signs, tick the RED box and take the child the emergency treatment area) If there are NO emergency signs, assess for Priority signs
Priority signs [3 TPR - MOB] Tiny baby Pallor Respiratory distress Malnutrition If there are priority
Temperature Poisoning Restless, Irritable, Lethergic Oedema signs, take the child to
Trauma Pain Referral Burns the front of the queue

TRIAGE PRIORITY LEVEL RED YELLOW GREEN Time triaged: .........|.........Hrs

Assess Yellow "Y" (Priority) and Green "Q" (Non urgent) priority level children on the queue with TEWS below

TEWS Younger than 3 years/Smaller than 95cm 3 to 12 years old/95 to 150cm


Parameters 3 2 1 0 1 2 3 3 2 1 0 1 2 3 ACTION FOR TEWS
Normal Unable Normal Unable R
Mobility 7 TEWS and Above
for age to move for age to walk
Respiration <20 20-25 26-39 40-49 >50 <15 15-16 17-21 22-26 27or> Emergency TEWS. Send to emergency room.
Start appropriate emergency treatment
Heart Rate <70 70-79 80-130 131-159 >160 <60 60-79 80-99 100-129 >130
Cold o
35 C - Feels Hot Cold o
35 C - Hot 3 -6 TEWS Y
Temperature o o >38.4oC o o o
<35 C 38.4 C <35 C 38.4 C >38.4 C Priority TEWS - Continue monitoring.
AVPU Alert Voice Pain Unresp. Confused Alert Voice Pain Unresp. Do investigations and give approprite treatment
Trauma No Yes No Yes 0-2 TEWS G
TOTAL Non urgent TEWS. Continue monitoring. Ensure
TOTAL TEWS that the child is seen within the specified time

Paediatric blood pressure reading in mm Hg. Triage Nurse ..............................Sign.....................Date......./........./........ Time:......./......

Systolic Diastolic Dr's Comment


Prem (<37cwksg) 39-59 16-39 ............................................................................................................................. .............
Neonate (0-28dys) 60-84 31-53 ............................................................................................................................. .............
Infant (0-12mon) 72-104 37-56
............................................................................................................................. .............
Toddler (1-3yrs) 86-106 42-63
Prescoolar (3-5yrs) 89-112 46-72
School age (6-12yrs) 97-120 57-80 Dr's Name..................................Sign.....................Date......./........./........ Time:......./......

Adapted from the Nursing & Midwifery Protocols 2017 and The South African Triage Scale (SATS)

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