MAKALAH SEMINAR KEGAWATDARURATAN PENGKAJIAN PRIMER DI KEPERAWATAN GAWAT DARURAT
DISUSUN OLEH KELOMPOK 2 ( A 2014 1) 1. 2. 3. 4. 5. 6. 7. . !. 10. 10. 11. 11. 12. 13. 13. 14. 15. 15.
AGUSTONO ANISA WULANDARI DIAH DIAH PRA PRATIWI TIWI WI WIDI DIAS ASTU TUTI TI DIAN EK EKA LESTARI FAIZAH ISNA ISNA FARIH ARIHA A MUH MUHTI KURNIA SANDI NESHA NURDILLA PRATIWI NI NINGSIH RU"I RU"IDA DA ULF ULFA SHINTA SHINTA RAHMA RAHMA NAT NATA S. TIARA TIARA SU#I SU#I ISWAND ISWANDHIE HIE "I#K "I#K$ $ SETI SETIAR ARINI INI WIND$ WIND$ OKTA OKTA"IANA "IANA $O"I $O"IA A RAHA RAHA$U $U
FAKULTAS ILMU KEPERAWATAN UNIVERSITAS RIAU 2017
KATA KATA PENGANTAR PEN GANTAR
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DAFTAR ISI KATA PENGANTAR……………………………………………………………………...i DAFTAR ISI………………………………………………………………………………….ii BAB I PENDAHULUAN
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3.1 KESIMPULAN............................................................................................................1! 3.2 SARAN........................................................................................................................1! DAFTAR PUSTAKA............................................................................................................20
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. P#$"a*ia# Circulation
S8* '>'''*, 9,,' ',* ,*%,, /+>%' 8+, , 8*',' &,+',. H'/8?8-', ,,, /9,9 8* /,' %-%- /,, +,%-,. D',8' 8* ',,+*, /,, -%, *''B '/8'= ,*'*,+',= ,*'/,= '/8+-',= /%,= *+-', ''= /%+%, capillary refill = , /%+%, /+8%*' %+'. O *,+, '%= , ,,, ,,,, '/8' -+%/,*, ,, ,% ,,, , %*%/ ,-, %%* -,%-'*, , +&,' /+,+,, , ,% -,+,*, '- %%* -,*%*, %/,, -'*, /,+,,. P9,9 ,' , -%*' --9%%*, /+,', +, ,,,B tension pneumothorax' cardiac tamponade' cardiac= spinal shoc , anaphylaxis. S-%, /+,+,, *+, , ,, ,+% '''>'*,' -,%' /,/,+, /,, /,' ,+, --,,' , '*8, , 9,'* (W'*'8 S*'+= 2000). L,*,,*, ,,- /*,&', +,,/ ,% '+*%,' /,'= ,,+, ,' B ,. #* ,' , -%,' ,*%*, #PR &'*, '/+%*,. 9. #PR ,+% +% ',*%*, ,-/,' >'9+',' ',/ %%* '%,*,. . K8+8 /+,+,, , ,/, -,,- *'%/, , /-9+', /*,, ,+, ,%. . P,/,' ,' +,', &'*, '/+%*,B
M%*, ,, ,,% ',*, M',' *%,', ,+, %-%- (*%,-,) I'>'*,' rate (,-9,= 8+-,= ,,% /,) -egularity . K,&' *%' %%* -', ,,, ,,,, '/8/+>%' ,,% '/8*', (capillary refill ). >. L,*%*, treatment +,,/ '/8/+>%'. 3.
P#$"a*ia# !e"el of Consciousness a# #isabilities
P,, primary survey= disability '*,&' , -%,*, *,, A"PU B A Alert = ,'% -+/8 %,+, , /,= -',, --,%' /+', , '9+'*,.
12
" ,ocalises= -%*' ',* %,' ,,% -%,+*, %,+, , ',* 9', '-+'. P responds to Pain only (,+% '',' -%, *-/, %*,' &'*, *+-', ,<, , '%,*, %%* -*,&' ,, %%* -+/8). U .nresponsive to pain= &'*, /,' ',* -+/8 9,'* '-%% +' -,%/% '-%% ?+9,. 4.
$%pose5 $%amine a# $"aluate
M,,*, /,*,', /,' , --+'*, +, /,, /,'. '*, /,' '%, --''*' +, + ,,% %, 9,*,= '-89'',' in#line /' %%* ',*%*,. L,*%*, log roll *'*, -,*%*, /-+'*,, /,, /%% /,'. $, /+% '/+,'*, ,,- -,*%*, /-+'*,, /,, /,' ,,, -*/8
/,'
,,
,-,
/-+'*,,
*+,.
S,
-%,
/-+'*,, , ,' ',*%*,= %%/ /,' , '-% ,, , &,, /+'?,' /,'= *%,' &'*, '/+%*, /-+'*,, %, (T+8= 2011). D,,- '%,' , '%, , +&,' -*,'- +,%-, , -,,- &'<,= -,*, -apid &rauma Assessment ,+% +, ',*%*,B
L,*%*, /-+'*,, */,,= += , *+-', /,, /,'.
P+,*%*, ',/ -%, %*, 9,+% , ,/, -,,- ,<, /,' , -%,' -,*%*, +,/8+,' /,, /,' , 9+/8' ',* ,9' ,,% *+''. (G'9+.= DS8%,.= P= 200!).
2.). Fr&at P#$"a*ia# A'%(a# F6RMAT PENGKAJIAN ASUHAN KEPERAWATAN GAWAT DARURAT 13
N,-, P*,&' B T,, P*,&', B R%, P*,&', B ,- B A.
BI6DATA PASIEN
N,-, B ' K,-' B P''*, B P*+&,,, B U', B S,% P+'*,, B N8 RM B D',8, M' B T,, M,%* RS B A,-, B B.
BI6DATA PENANGGUNG JAWAB
N,-, B ' K,-' B P''*, B P*+&,, B H%9%, , K' B A,-, B . PENGKAJIAN PRIMER Airways /*a!a# #a,a'
S%-9,, B ( ) @, A' ( ) @+88/,- ( ) D,+, ( ) S/%%( ) L'+ S%,+, ,/,B ( ) Snowring 14
( ) /urgling ( ) reathing /-r#a-a'a#
S,* ,B ( ) A*'?', ( ) T,/, ,*'?', ( ) M%,*, 88 ,-9,, F+*%'B-' I+,-,B ( ) T+,%+
( ) T',*
K,,-,B ( ) D,,-
( ) D,*,
R>* 9,%*B ( ) A,
( ) T',*
@,%*B ( ) P+8%*'>
( ) N8 /+8%*'>
S/%%-B ( ) A,
( ) T',*
W,+,B . K8''B .. @%' ,>,B ( ) -onchi
( ) Crealess
( ) 0hee1ing
( ) .. @GAB . Circulation /Sir"%!a'i
S'+*%,' P+'>+B N,'B .. -' I+,-,B ( ) T+,%+
( ) T',*
D%B ( ) L-,
( ) K%,
( ) T',* *%,
TDB .--H E*+-',B ( ) #,8'
( ) P%,
N+' ,,B ( ) A,
( ) K-+,, ( ) T',* 15
K,+,*+''* +' ,,B ( ) M,/
( ) M9,+
( ) S/+' '%%*%%* ( ) S/+' ''-/, 9, 9+, Capillary refill2 ( ) 3 '*
( ) 3 '*
E-,B ( ) $,
( ) T',*
L8*,' -,B ( ) M%*, ( ) T%*,'
( ) T,, ( ) A,,+*,
#isability
( ) Alert /+,', ( ) ,oice respons +/8 +,,/ %,+, ( ) Pain respons +/8 +,,/ +' ( ) .nrespons! ',* 9+/8 ( ) R,*' /%/' $&sposure/en"ironment/e"ent
P-+'*,, %+% 9,', %9% +,,/ ,,, &&, , /+,+,, , /,, '/8+-'. P-+'*,, /%&, , , ',*%*,B Event /9,9 *&,',B
PENGKAJIAN PRIMER '( Airway )
,. A,*, S%-9,, & ,/,9, ,'= 9+8*8/,-= ,+,= /%%-+C 9. @%' ,/,C *( reathing )
,. A,*, ,* ,/,= >+*%' , '+,-, ,/,C 16
9. ' /+,/,,= /8, ,/, (++,*' I#= 88 9,% /+,/,,= )C . A,*, +>* 9,%* , &' 9,%*, +, *,+,*+''* /%%-C . @,,'-,,*, ,' @GAC . A,*, %,+, ,/, ,98+-, ( Circulation
,. @+,/, >+*%' ,' , *,, ,+, +, *,+,*+''*,C 9. @,,'-,,*, ,*+,= <,+, *%'= capillary refill , -,,C . A,*, +' ,, , 9,,'-,, *,+,*+''*,C ,( #isability
@,,'-,, *%,', , *%,', *,,+,, ( $%posure
,. A,*, &&, %*, , 9,,'-,,*, *,+,*+''*,C 9. A,*, /+,+,, , 9,,'-,,*, *,+,*+''*,C
BAB III PENUTUP ).1 KESIMPULAN P*,&', /+'-+ 9+%&%, -,%' , +, *8'' , -,,-
,<, /,'. P*,&', /+'-+ -',*, ?,%,' , '-,'= /*', , -,,&- +, +,,/ *8-/'*,' ,*'9, +,%-, /,+, , -,,*'%/,. T%&%, ,+' /*,&', /+'-+ ,,, %%* -''>'*,' , --/+9,'*' , +, -,,, , -,,- *'%/,. P+'8+', , ',*%*, /,, /*,&', /+'-+ ,,+, ,' (F%= 200!) B
Airway maintenance , cervical spine protection)
Breathing , oxygenation)
Circulation , *8+8 /+,+,, *+,. 17
Disability/-+'*,, %+88' '*,.
Exposure , *8+8 '*%,.
).2 SARAN P%' 9,,* 9+,+,/ /,+, /-9,, %%* --9+'*, *+''* , ,+, ,
--9,% */,, /%' -' -/%+,, -,*,, '' , /%', -,*,, ' *-/,,*-/,, 9+'*%,. S-8, -,*,, '' 9+%, 9,' /%' /,, *%%, &%, /,+, /-9,, /,, %-%-,. T+'-, *,'.
DAFTAR PUSTAKA
#%+'= K.= M%+/= M.= H8= S.= , L<'= M.. (200!). T -+ %+' ,- /+8B , +%%+ >+,-<8+* >8+ , -,' ,//+8,. Australasian Emergency %ursing 3ournal = 12J 130136 D/ -,'. (2004) . *a+or diagnosis fisi . ,*,+,B EG#. D'*, $,,, A-9%, G,<, D,+%+, 11. (2010). @,' T+,%-, L'> S%//8+ , @,' #,+', L'> S%//8+ E'' K',. $,,, A-9%, G,<, D,+%+, D'*, RSUP D+. M. D&,-' P,,. (2006). P,', P,%,, P+', G,<, ,+%+, (PPGD). RSUP. D+.M.D&,-' P,,. D&%-,,= A'. (2011). P+,+,, A*% S,%+, #+, @,', A,. FK. UNPAD. E-+ N%+ A8','8 (2007). Sheehy4s manual of emergency care 5 th edition. S. L8%' M'8%+' B E?'+ M89. F%= G8+',. (200!). Emergency medicine 6th edition. A%+,', B E?'+. G'9+= G+8+.= DS8%,= P+.= P= @,+9,+,. (200!). P,' ,- +8%' -', ,+ /+'-,+ , 8,+ %+?. S, M,8 #8% EMS A.
18
L8-9,+8= D. (2005). Patient
asessment .
IB N<9%+ L.= #+' L.M.= . Sheehy7s
manual of emergency care= 6. P',/',B M89. L,+,= ,/+'= @%'= A,+'*,= S,+%'. (2011). U+,88+,>' T8+,*. 3urnal -espiratori 8nonesia ,olume 9: ',* ,+' /B&%+,+/'+88'.8+ ,, 2 A/+' 2013. Lyer = P.W.= #,-/= N.H.(2005).
D8*%-,' K/+,<,,= S%,% P*,, P+8
K/+,<,,= E'' 3. ,*,+,B EG# M,'' MR= G, AT.(2011). Emergency care and the law. M,+,B A/ P%9','8. M,+%,'= A'* $%',''. (200!). Asuhan egawatdaruratan. ,*,+, B T+, I>8 M', M'. P+,''8+ E-+ M', T'',. (2012). Clinical practice guidelines for pre# hospital emergency care. I+, B P+H8/', E-+ #,+ #8%'. IS@N !70 !571022. T N,'8, I'% >8+ H, , #'', E. (2007). ;ead in+ury2 triage' assessment' investigation and early management of head in+ury in infant' children and adults. L88B T N,'8, I'% >8+ H, , #'', E T+8= A8. (2006). F'+ ,' 5 ''8. A' 9,,, +. H%+',<,' H,+,8. E. R', A'*,<,'. ,*,+, B PT. G8+, A*,+, P+,,-,.
19
