3. Process of Triages Assessment 1.Across the room assessment 2. Triage physical assessment 3.Triage history 4.Triage decision
4. Across the room assessment A Airway status B Breathing status C Circulatory status D - Disability
5. Triage Physical Assessment 犢犖犢犖迦見犖÷顕犖 : 犖犖犖萎犖÷鹸犖犢犖犢犖犖犖犖犖犖ム幻犖 + 犖犖園犖犖犖萎硯犖園犖巌賢犖∇犖迦犖∇犖犢 犖犖園硯犖犢犖犢犖犖犖迦牽犖犖園犖犖犖萎硯犖園犖 : O L D C A R T O : Onset of symptom L : Location Of Problem C : Characteristics the patient uses to describe the symptom D : Duration of symptom A : Aggravating factors R : Relieving factors T : Treatment administered before arrival
6. Triage History C I A M P E D S C : Chief complaint I : Immunization A : Allergies M : Medication P : Past medical history E : Events surrounding D : Diet S : Symptom
7. Triage Decision 1. Immediately life-threatening : 1A or 1B 1A : multiple trauma + life threatening 1B : life threatening 2. Imminently life threatening 3. Potential life-threatening 5. Least urgent 4. Potential serious Australasian Triage Scale : ATS
8. -Multiple-trauma requiring resuscitate. Complex traumatic 犖犖犖萎犖÷鹸犖犢犖ム鍵犖犖園犖犖迦犖犢犖犖÷犖園犖犖園犖犖 1A (4hrs.+30mins.) - Minor wound small abrasion / Minor pain / Follow up /Minor symptom of low-risk conditions. 犖犖犖萎犖÷鹸犖犢犖ム鍵犖犖園犖犖迦犖 120 犖犖迦犖 5 ( 30 MINS) Mild haemorrhage ,Moderate pain , Minor head injury ,no loss of conscious Vomiting or diarrhea without dehydrate 犖犖犖萎犖÷鹸犖犢犖ム鍵犖犖園犖犖迦犖 60 犖犖迦犖 4 (50 MINS) Closed small fracture ,Persistent vomiting,Head injury with short loss conscious now alert. etc. 犖犖犖萎犖÷鹸犖犢犖ム鍵犖犖園犖犖迦犖 30 犖犖迦犖 3 (1HR+15MINS) Chest pain of likely cardiac nature. Very severe pain any cause. Hypotension with haemodynamic effects. Severe respiratory distress. Drowsy,decrease responsive any cause (GCS < 13) 犖犖犖萎犖÷鹸犖犢犖ム鍵犖犖園犖犖迦犖 10 犖犖迦犖 2 (2HRS+30MINS) . Cardiac arrest / Respiratory failure Ongoing/prolong seizure 1B (3hrs+15mins) Clinic descriptors Response Triage scale
9. Process of Triage Nurse 1. Assessment 2. Priority of care ( Triage category ) 3. First aid 5. Public relations 6. Diagnostic , therapeutic intervention 4. Referral 7. Documentation
