Nursing Triage Tool

Chest pain

Are you experiencing chest pain?

No chest pain. Yes I am.

Fever

Do you have a temperature above 37.5°C or below 36.0°C?

No. Yes.

Shortness of breath

Are you experiencing shortness of breath?

No. Yes, a new onset shortness of breath on moderate exertion. Eg. Walking to the shops. Yes, a new onset shortness of breath on minimal exertion Eg. Moving from bed to chair. Yes, shortness of breath at rest Eg. Difficulty talking in full sentances.

Vomiting

Are you experiencing vomiting?

No vomiting. Yes, one episode in 24 hours. Yes, two to four episodes in 24 hours. Yes, more than six episodes in 24 hours.

Diarrhoea

Are you experiencing diarrhoea?

No diarrhoea. Yes, two to six bowel movements in 24 hours. Yes, seven of more bowel movements in 24 hours.

Constipation

Are you constipated? If yes, when was the last time you opened your bowels?

I'm not constipated. Mild. No bowel movement for 24 hours. Moderate. No bowel movement for 48 hours. Severe. No bowels movement for 72 hours.

Rash

Do you have a rash?

I don't have a rash. Mild rash covering 10% of body, with no itcing or redness. Covering over 30% of your body, with any of the following redness, ithcing, burning, skin tightness.

Peripheral Neuropathy

Do you have pins and needles in your hands or feet?

I don't have pins and needles. Pins and needles with no pain or swelling in hands or feet. Pins and needles pain or swelling in hands or feet, difficult perform fiddley task such as fastening buttons on a shirt. Pins and needles with severe pain, swelling and blistering.

Waiting room

Please take a seat, a nurse will call you shortly.

Please dial 999 if you need immediate medical intervention, this is an advisory service only.