Scribd Logo
Upload

Welcome to Scribd!

  • Askep Gawat Darurat in Hospital

    Uploaded by

    Adi Saputra
    4 views26 pages
    This document provides guidelines for emergency nursing care for non-trauma and trauma cases. It outlines the primary and secondary assessments for these cases. The primary assessment involves assessing the airway, breathing, circulation, disability, and environment. Specific things to examine include patency of airway, breathing sounds, vital signs, oxygen saturation, and level of consciousness. The secondary assessment involves full vital sign monitoring, interventions like IV placement, and a full head-to-toe examination. Goals of care should be specific, measurable, achievable, realistic and focused on observable client behaviors and responses.

    Original Description:

    Original Title

    ASKEP GAWAT DARURAT IN HOSPITAL

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document provides guidelines for emergency nursing care for non-trauma and trauma cases. It outlines the primary and secondary assessments for these cases. The primary assessment involves assessing the airway, breathing, circulation, disability, and environment. Specific things to examine include patency of airway, breathing sounds, vital signs, oxygen saturation, and level of consciousness. The secondary assessment involves full vital sign monitoring, interventions like IV placement, and a full head-to-toe examination. Goals of care should be specific, measurable, achievable, realistic and focused on observable client behaviors and responses.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    4 views26 pages

    Askep Gawat Darurat in Hospital

    Uploaded by

    Adi Saputra
    This document provides guidelines for emergency nursing care for non-trauma and trauma cases. It outlines the primary and secondary assessments for these cases. The primary assessment involves assessing the airway, breathing, circulation, disability, and environment. Specific things to examine include patency of airway, breathing sounds, vital signs, oxygen saturation, and level of consciousness. The secondary assessment involves full vital sign monitoring, interventions like IV placement, and a full head-to-toe examination. Goals of care should be specific, measurable, achievable, realistic and focused on observable client behaviors and responses.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 26

    ASUHAN KEPERAWATAN

    GAWAT DARURAT
    “IN HOSPITAL”
    Ns. NURDIN, S.Kep., M.Kep
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    A. KASUS NON TRAUMA
    (PRIMARY ASSESSMENT) 1. PENGKAJIAN
    ❖ Kepatenan jalan napas
    ❖ Obstruksi : ( parsial or total) darah,
    ❖ Deformitas
    sputum, lidah, muntah, benda asing dan
    ❖ Contusio
    oedema. ❖ TD, MAP ❖ Abrasi
    ❖ Suara napas abnormal gurgling, stridor, ❖ PP (N) ❖ Penetrasi
    snoring, wheezing dan ronki. ❖ CRT ❖ Laserasi
    ❖ Head tilt, chin lift, jaw thrust, ❖ Sianosis ❖ Edema
    oropharyngeal aiway, nasopharyngeal ❖ Akral dingin ❖ Combusti
    airway, supraglotik airway (LMA), ETT, ❖ Perdarahan
    suction, servical collar modified jaw trurst ❖ Turgor
    ❖ Attention Look, Feel and Listen. ❖ diaphoresisi

    EXPOSURE &
    AIRWAY BREATHING CIRCULATION DISABILITY
    ENVIROTMENT

    ❖ Gerakan dinding dada


    ❖ Irama napas
    ❖ Pola napas
    ❖ Suara napas ❖ Tingkat Kesadaran : AVPU dan
    ❖ Cuping hidung GCS
    ❖ Retraksi otot pernpasan. ❖ Refleks cahaya: isokort, unisokort,
    ❖ Frekwensi pernapasan miosis, midriasisi, pinpoint.
    ❖ Saturasi oksigen ❖ Refleks fisiologis dan patologis:
    ❖ Attention R:……x/menit and terpi patella, kerning dan babinzky.
    oksigen
    ❖ Kekuatan otot

    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    B. KASUS TRAUMA
    (PRIMARY ASSESSMENT)
    ❖ Kepatenan jalan napas
    ❖ Obstruksi : ( parsial or total) darah,
    ❖ Deformitas
    sputum, lidah, muntah, benda asing dan
    ❖ Contusio
    oedema. ❖ TD, MAP ❖ Abrasi
    ❖ Suara napas abnormal gurgling, stridor, ❖ PP (N) ❖ Penetrasi
    snoring, wheezing dan ronki. ❖ CRT ❖ Laserasi
    ❖ Head tilt, chin lift, jaw thrust, ❖ Sianosis ❖ Edema
    oropharyngeal aiway, nasopharyngeal ❖ Akral dingin ❖ Combusti
    airway, supraglotik airway (LMA), ETT, ❖ Perdarahan
    suction, servical collar modified jaw trurst ❖ Turgor
    ❖ Attention Look, Feel and Listen. ❖ diaphoresisi

    EXPOSURE &
    AIRWAY BREATHING CIRCULATION DISABILITY
    ENVIROTMENT

    ❖ Gerakan dinding dada


    ❖ Irama napas
    ❖ Pola napas ❖ Tingkat Kesadaran : AVPU dan
    ❖ Suara napas GCS
    ❖ Cuping hidung ❖ Refleks cahaya: isokort, unisokort,
    ❖ Retraksi otot pernpasan. miosis, midriasisi, pinpoint.
    ❖ Frekwensi pernapasan
    ❖ Refleks fisiologis dan patologis:
    ❖ Saturasi oksigen
    patella, kerning dan babinzky.
    ❖ Attention R:……x/menit and terpi
    oksigen ❖ Kekuatan otot

    nsnurdinmwuim@gmail.com
    LANJUT ❖ SAMPLE/MONACO
    ❖ History: MIVT ▪Sign
    (SECONDRY ASSESSMENT) ▪Alergi
    ▪ Mechanism
    (mekanisme) ▪Medikation
    ❖ Vital Sign ▪Pertinent medical
    ❖ EKG ▪ Injuries suspected
    (dugaan adanya history/Past illness
    ❖ NGT ▪Last meal
    ❖ Folley kateter cedera)
    ▪ Vital sign on scene ▪Events
    ❖ Oksimetri ❖ Head to-toe
    ❖ CT Scan (TTV ditempat
    kejadian) Examination
    ❖ Pemeriksaan lab ▪ IAPP
    ❖ Rontgen ▪ Treatmen received
    (perawatan yang ▪ IPPA
    ❖ Endoskopi
    telah diterima)

    Full set of vital signs, History and Head to Toe Inspect the
    five interventions and Give Comfort Measures Examination Posterior Surfaces
    facilitation of family

    nsnurdinmwuim@gmail.com
    ❖ Provokes/palliatif, Quality, ❖ Deformitas
    Region, Skala and Time ❖ Contusio
    (PQRST) ❖ Abrasi
    ❖ Penetrasi
    ❖ Laserasi
    ❖ Edema
    ❖ Combusti
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    ➢ Specific: tujuan harus spesifik tidak boleh memiliki arti ganda, tujuan
    dan hasil difokuskan kepada klien yang mencerminkan perilaku serta
    respon klien yang dapat diperkirakan
    ➢ Measureable: tujuan dapat di ukur khususnya pada prilaku klien yang
    dapat dirasakan, dilihat dan diraba.
    ➢ Achievable : tujuan yang harus dicapai dituliskan dalam istilah yang
    dapat di ukur sehingga memungkinkan perawat dapat mengukur serta
    menilai secara objektif perubahan status klien.
    ➢ Realistic: tujuan dapat dipertanggungjawabkan secara ilmiah
    diharapkan singkat dan jelas serta klien bisa merasakan pencapaian
    ➢ Time: Batasan waktu yang dapat membantu perawat dank lien dalam
    menetukan kemajuan dengan cepat dan jelas.
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    nsnurdinmwuim@gmail.com
    Thank You
    Insert the Sub Title of Your Presentation

    You might also like