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  • Lembar Triage: No. RM: Nama: Tanggal Lahir: L/P Alamat

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    Uci Nurse Triase
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    This document appears to be a triage form from a hospital emergency room. It contains fields to record information about a patient such as their name, date of birth, symptoms, vital signs, level of consciousness, and triage priority level (red, yellow, green). It also includes sections to note any allergies, behavioral issues, and the triage officer's name. The triage form is used to assess patients and determine the urgency of their needs upon initial presentation to the emergency department.

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    TRIAGE NEW

    Original Title

    Lembar Triage II

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    This document appears to be a triage form from a hospital emergency room. It contains fields to record information about a patient such as their name, date of birth, symptoms, vital signs, level of consciousness, and triage priority level (red, yellow, green). It also includes sections to note any allergies, behavioral issues, and the triage officer's name. The triage form is used to assess patients and determine the urgency of their needs upon initial presentation to the emergency department.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    11 views1 page

    Lembar Triage: No. RM: Nama: Tanggal Lahir: L/P Alamat

    Uploaded by

    Uci Nurse Triase
    This document appears to be a triage form from a hospital emergency room. It contains fields to record information about a patient such as their name, date of birth, symptoms, vital signs, level of consciousness, and triage priority level (red, yellow, green). It also includes sections to note any allergies, behavioral issues, and the triage officer's name. The triage form is used to assess patients and determine the urgency of their needs upon initial presentation to the emergency department.

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    of 1

    RUMAH SAKIT UMUM No. RM : RM : 1.

    4
    DAERAH PLOSO KABUPATEN Nama :
    JOMBANG Tanggal lahir : L/P
    Alamat :

    LEMBAR TRIAGE No Bed :


    Tanggal masuk : Jam masuk : Jam mulai diperiksa : Jam selesai triage :
    Jenis kasus :  Trauma  Non Trauma  Obstetri Diantar polisi :  Ya  Tidak
    Cara datang Komunikasi dari Rujukan
     Kendaraa pribadi  Ambulance  Ya  Tidak Tgl & Jam :
     Kendaraan umum Rujukan dari :
    Tgl & Jam Kejadian : Tempat Kejadian :
    Keluhan Utama :

     MERAH  KUNING  HIJAU


    NON FALSE
    PEMERIKSAAN TANDA VITAL EMERGENCY URGENT
    URGENT EMERGENCY
    JALAN NAFAS  Sumbatan  Bebas  Bebas  Bebas  Bebas
    PERNAFASAN Sa O2 :  Henti Nafas  RR > 34 x/mnt  RR > 34 x/mnt
    ……………….  Gasping  SaO2 < 92 %  Mengi  Normal
    %  Sianosis  SaO2 ≥ 92 %
    Frekuensi Neonates Neonatus Neonatus Neonatus  Normal
    nafas :  Apnea  RR > 80 x/mnt  RR 60-80 x/mnt  RR 40-59
    …………x/mnt  Sianosis  Retraksi sedang  Retraksi ringan x/mnt
     Retraksi berat
    SIRKULASI Frekuensi  Henti jantung  Nadi teraba lemah  Takikardia  Nadi 60-
    nadi :  Nadi tdk teraba  Bradikardia (101-159 x/mnt) 100 x/mnt
    …………x/mnt  Pucat (pale) (≤50x/mnt)
     Akral dingin  Takikardia
    basah (≥160x/mnt)
    Neonatus Neonatus Neonatus
     Nadi < 100 x/mnt  Nadi Neo >160  Nadi 100-
     Neonatus CRT > 3 x/mnt 160 x/mnt
    dtk  Neonatus CRT
    < 3 dtk
    Tekanan darah Tekanan darah :  Hipertensi  TDS 120 - 219  TDS 90
    : ………mmHg TDS ≥ 220 mmHg mmHg atau -119 mmHg  Normal
    ………mmHg atau TDD 70 - 119 atau
    TDD ≥ 120 mmHg mmHg TDD 70-
    atau 119 mmHg
     Hipotensi TDS ≤
    80 mmHg
     Akral Dingin
     CRT > 2 detik
    MATERNITAS
     Hamil ≥ 20 mgg,
    TDS ≥ 160 mmHg
    atau
    TDD ≥ 110 mmHg
    KESADARAN GCS  Kejang  Verbal respon  GCS > 13  GCS 15  GCS 15
    E :  Unrespon  GCS ≤ 13  Luka resiko
    V :  Pain Respon  Typical chest pain infeksi
    M:  Trauma curiga
    fraktur
    SUHU : 0
    C Neonatus Neonatus  36,5 0C -  36,5 0C -
     Neonatus < 36,5  > 37,5 0C 37,5 C0
    37,5 0C
    0
    C
    AREA P1 P2 P3
    RESPON TIME 1 menit 10 menit 60 menit
    ALERGI GANGGUAN PERILAKU
     Tidak Ada Alergi  Marah PETUGAS TRIAGE :
     Alergi Obat :  Cemas
     DOA …………………………  Panik
     Alergi Makanan :  Membahayakan diri dan orang lain ( ……………………………………. )
    ………………………. Tanda tangan & Nama terang

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