Triage Dewi

7/29/2019 Triage Dewi

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TRIAGE

Dewi Kartikawati


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HISTORY

The formal definitionof TRIAGE takenfrom the French wordtrier which means

to sort into 3 groups The classification of

patients originated onthe battlefields of

World war I


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Cont.

The concept of triage hasalso been applied todisasters

Implementation of triage

process in ED wasinitiated in the late 1950sand the early 1960s

Triage ialah suatu proses

dimana pasien digolongkanmenurut tipe dan tingkatkegawatan kondisinya.


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Principles Of Triage

1. Immediate & timely

2. Adequate and accurate assessment

3. Assessment based decisions4. Interventions according to acuity

5. Patient satisfaction

6. Complete documentation


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Konsep Triage

Tujuan utama untuk mengidentifikasikondisi yang mengancam nyawa

Tujuan kedua untuk memprioritaskanpasien berdasarkan keakutannya

Pengkategorian mungkin ditentukansewaktu-waktu

Jika ragu, pilih prioritas yang lebih

tinggi untuk menghindari penurunantriage


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Triage Classification

Triage classification based onknowledge, available data andthe current situation.

Triage classification oftenused : Priority 1 or Emergency

Priority 2 or Urgent Priority 3 or Non Urgent


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Sistem Klasifikasi


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Triage 9

Sistem KlasifikasiMenggunakan nomor, huruf atau tanda

Prioritas 1 atau EmergensiPasien dgn kondisi mengancam nyawa,

memerlukan evaluasi dan intervensi segera

Pasien dibawa ke Ruang Resusitasi

Waktu tunggu nol


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Triage 11

Prioritas 2 / Urgent Pasien dgn penyakit yg akut

Mungkin membutuhkan trolley,

kursi roda atau jalan kaki Waktu tunggu 30 menit Area Critical care


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Triage 13

Prioritas 3 / Non Urgent

Pasien yg biasanya dapat berjalan dgn masalah

medis yang minimal

Luka lama

Kondisi yang timbul sudah lama

Area Ambulatory / Ruang P 3


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Triage 15

Prioritas 0 / 4 Kasus kematian Tdk ada respon pada segala rangsangan

Tdk ada respirasi spontan

Tdk ada bukti aktivitas jantung Hilangnya respon pupil thd cahaya


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START METHODE( SIMPLE TRIAGE & RAPID TREATMENT)

Respiration None open the airway

Still none deceased

Restored immediate

Present

Above 30

immediate

Below 30 check

perfusion


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Cont.

Perfusion

Radial pulse absent

or capillary refill

>2 sec immediate Radial pulse

present or capillary

refill < 2 sec checkmental status


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Cont.

Mental status

Can not follow

simple commands

(unconscious or

AMS)

Immediate Can follow simple

commands

Delayed
http://www.dailytimes.com.pk/images/2004/10/18/18_10_2004_brain%20anatomy.jpg


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Pengkajian Triage( Soap System ) Gathers subjective and objective data for

quick assessment

Enables accurate planning for nursing

intervention and immediate management

Is a 2 minutes process

Is effective for documentation of nursing

assessment


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WHAT IS SOAP ?S - SubjectiveCollect data about whatthe patient is tellingyou.O - Objective

What are you actuallyseeing?ParametersA - AssessmentAssess the situation.

P - PlanEstablish a plan for thepatient.


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TRIAGE PROCESS - SUBJECTIVE

Collect subjective data

Ask open ended questions e.g. Why

did you want to see a doctor? Gather other relevant information

Obtain brief one-line statements.


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QUESTIONS TO ASK

Chief complaint?

Location? Site of pain?

Pattern? Radiation?

Time of onset? Duration?

Frequency?

Character, Quality? e.g. ?Colicky


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Cont..

Effects to other system and activitiese.g. fever (1 week) & now havingbleeding PR

Effort to treat ? seen by GP/Polyclinic

self medicate

Past medical history & drug allergy


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TRAUMA CASES

Mechanism of injury must be noted.

1. Ask how the patient was injured.

2. Other Questions

When did the accident occur?How fast was the car travelling?

Where were you sitting?

Were you wearing a seat belt?

Did you hit the dashboard and were you

thrown against another car?

Did you lose consciousness?


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Pain assesment

Pain is one of the most commandcomplaints. PQRST is a helpful method of

evaluating pain.

PProvokes / palliates / pattern

What precipitated the pain ?

What makes it better or worse ?

What were you doing when it started

?


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Cont.

Q quality Describe the quality of the pain

dull,colicky,sharp ?

What does it fell like ?

Rregion

Where is the exact location of the pain ? Ask

patient to point to the area

Does the pain spread to anywhere else?


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Cont..

S- severity How severe is the pain or symptom?

Use rating scale ex.number rating, visual

analog scale, Are there any associated symptoms?

T - time

When did the pain start and how long did it

lasts (duration) ?


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O - OBJECTIVECollect objective data :General

Mode of arrival to A&E

Level of consciousness; GCS (Trauma Case)

Patients general appearance using yoursenses

Vital signs

temperature,pulse, respiration & BP


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A - ASSESSMENT

Assess and

evaluate patient

from subjectiveand objective

data collection.


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P - PLAN Establish your priority & direct to appropriate

area.

Carry out further tests if required

ECG

Peripheral blood glucose Urine Lab stix/Combur 9; Urine for inspection

Institute first aid management:

Immobilize fracture

Put on cervical collar First aid dressing

X-ray


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Triage Documentation Goals of documentation:

To support the triage dicision

To communicate essential information

to subsequent care providers

To meet medical legal requirements


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What must be documented ??? Time patient was triaged ?

Chief complaint & associated symtoms

Past medical history

Allergies

Vital signs

Subjective & objective assesment

Acuity category


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Cont

Diagnostic tes ordered

Intervention rendered

Disposition

Reevaluation and changes in condition


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Triage - Extremity Trauma 34

Questions & Answers


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Wassalamualaikum

Documents

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