Pengkajian Triase: Resusitasi (P1) Emergency (P2) Less Urgent (P4)

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PENGKAJIAN TRIASE

PEMERIKSAA RESUSITASI EMERGENCY TANDA URGENT LESS NON URGENT


N (P1) (P2) VITAL (P3) URGENT (P5)
(Examination) (P4)
Sumbatan Bebas TD/BP Bebas Bebas Bebas
JALAN NAPAS
(Obstruction) (Patent) (Patent) (Patent) (Patent)
(Airway)
……… mmHg
Henti napas Frek. Napas
(breathing arrest) RR > 32 x/mt (RR) RR 24-32 x/mt
RR < 10 x/mt Wheezing Wheezing
Sianosis ………….x/mnt
PERNAPASAN Neonatus Neonatus Neonatus
Normal Normal
(Breathing) Apneu RR > 80 x/mnt RR > 60/mnt
RR < 60/mnt Atau < 40 x/mnt
Sianosis sentral,
Sianosis sentral, Sianosis sentral, Menghilang dgn
Menetap dgn O2 Menetap dgn O2 O2
Henti jantung Nadi lemah Frek. Nadi
(cardiac arrest) (Weaknes Pulse) (HR) Frek.Nadi (HR)
Nadi tidak Nadi < 50 x/mnt 120-1 50 x/mnt
teraba Nadi > 150 x/mnt ………….x/mnt
(dewasa)
Neonatus Neonatus Neonatus
Nadi < 60 x/mnt Nadi < 100 x/mnt Nadi < 160 x/mnt
SIRKULASI
Pucat Pucat TD Sistol Normal Normal
(Circulation)
(Pale) (Pale) > 160 mmHg
Akral dingin Akral dingin
(Clammy) (Clammy) TD Diastol
CRT < 2 detik > 100 mmHg

Neonatus Neonatus Neonatus


CRT > 3 detik CRT > 3 detik CRT > 3 detik
GCS < 9 GCS < 9 – 12 GCS >13 GCS = 15 GCS = 15
KESADARAN Neonatus Neonatus SB: ………⁰C Neonatus Neonatus Neonatus
(Disability) SB < 36.5 ⁰C SB < 36.5 ⁰C SB > 37.5 ⁰C 36.5 – 37.5 ⁰C 36.5 – 37.5 ⁰C
Atau < 36.5 ⁰C

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