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Uvod: Triaža je razvrščanje pacientov glede na njihovo potrebo po zdravstveni oskrbi. Je kontinuiran in dinamičen proces, ki se prične na kraju nezgode in konča z oskrbo pacienta. Izvaja se jo v različnih okoljih in pod različnimi pogoji. Medicinska sestra ima pri izvajanju triaže pomembno vlogo, saj najpogosteje prav ona prva vzpostavi stik s pacientom. Namen: Namen diplomskega dela je predstaviti triažne sisteme in triažo na terenu ter s pomočjo strokovne in znanstvene literature ugotoviti, kakšna je vloga in pomen medicinske sestre pri triaži pacientov na terenu ob različnih dogodkih. Metode: V diplomskem delu smo uporabili kvalitativno analizo empiričnih in teoretičnih člankov v slovenskem in angleškem jeziku, ki so opisovali triažo in triažne sisteme v povezavi z medicinsko sestro. Ključne besede v angleškem jeziku so bile: triage, nurse, paramedics, mass disaster and emergency medical treatment. Časovni okvir pregledanih člankov je bil od leta 2005 do leta 2017. Pregledali smo 22 člankov. Rezultati: Triaža se prične z dvigom nujnega telefonskega klica. Tu mora medicinska sestra prevzeti vodilno vlogo komunikacije, da si lahko pridobi pomembne informacije. Prva stopnja triaže po triažnem sistemu SIEVE, ki se uporablja v Sloveniji, je primarna triaža. Med njo začnemo tudi s prvimi najbolj nujnimi ukrepi za preživetje, kot so sprostitev dihalne poti, zaustavitev večje krvavitve, namestitev nezavestnega v položaj za nezavestnega in pri otrocih 5 začetnih vpihov (pri uporabi triažnega sistema JumpSTART). Druga stopnja triaže je sekundarna triaža, izvaja se po triažnem sistemu SORT. V sekundarni triaži se paciente ponovno razdeli po triažnih kategorijah in začne se z izvajanjem zdravstvene oskrbe. Zaključek in refleksija: Dobra triaža pacienta je ključni element pri prepoznavi ogroženosti pacienta v večjih nesrečah, zato je pomembno, da so medicinske sestre, ki delujejo v službah NMP dobro pripravljene na to. Introduction: Triage is the classification of patients, based on the severity of their condition. It is a continuous and dynamic process. Triage begins at the scene of an accident and it ends with the care of the patient. The procsess is implemented under, and on, different conditions. Triage nurse has an important role in a process . She first contacts the patients and makes a quick evaluation of their condition. Purpose: Our thesis presents triage systems and triage in the field (terrain). Through professional and scientific literature we will try to determine the role and importance of the nurse in the triage of patients in the field (terrain) at different circumstances. Methods: We used a qualitative analysis of empirical and theoretical articles, written in Slovenian and English language. The articles are about triage and triage systems in a relation to a nurse. English key words: triage, nurse, paramedics, mass disaster, emergency medical treatment. The time frame of the reviewed articles was from 2005 to 2017. We have reviewed 22 articles. Results: Triage begins with an emergency call. A nurse must take on the leading role in gaining all the important information of determining the priority of patients' treatments based on the severity of their condition. First level of triage in the SIEVE triage system, which is used in Slovenia – this is the primary triage. At this stage, we begin with the most urgent survival measures, such as relaxation of the respiratory tract, preventing major bleeding, setting up unconscious in a position of unconsciousness and when it comes to children, with 5 initial Spills (when using the jump start system). The second triage stage is a secondary triage (it is used in a SORT system). In the secondary triage, patients are sorted once again into triage categories, and then we can start performing medical help. Conclusion and reflection: A good patient triage is the most essential element in identifying the patient's risk in a mass disasters. It is important, that nurses who work in ER services are well prepared. |
