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KGD 2020
Client Assessment
 At the end of the lecture students able to
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 Define subjective assessment

 Explain the steps of
subjective assessment survey
 Describe primary survey
 Describe secondary survey
 Describe tertiary survey
 Demonstrate professionalism
in assessing clients in
emergency situation
 Emergency Nursing Assessment
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 Subjective
assessment
 Thru survey:
Primary survey
Secondary survey
Tertiary survey
 Subjective Assessment
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 Data collected base on clients’

complaint
 Source :
 client, family, witness, fireman,
police, ambulance team.
 Data collected from:
 L = location
 O = occasion
 T = time & type
 A = associating factor
 R = relieving
 P = past medical history
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 PRIMARY SURVEY
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Is an assessment: Apakah penilaian:

 goals are to identify tujuannya adalah untuk
mengidentifikasi
 clients’ problems - masalah klinis
 Life threatening -Korban yang mengancam
casualty jiwa
 Critical condition -Kondisi kritis
memberikan tindakan
 provide immediate segera
action memberikan informasi
 gives information about tentang ABCD & GCS
dilakukan dalam waktu
ABCD & GCS
30-60 detik.
 done within 30-60 sec.
 Glasgow Coma Scale
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Eye Opening
 Spontaneous……….4

 To speech…………..3

 To pain..……………2

 None………………1
 Cont.
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Verbal response
 Oriented………………..5
 Confused, disoriented ….4
 Inappropriate words . ….3
 Incomprehensible sounds ..2
 None……………………1
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Best motor response

 Obey………………………. 6
 Localize to pain . . .…………5
 Withdrawal (flexion) ……….4
 Abnormal flexion posturing …3
 Extension posturing …………2
 None.………………………..1
 GCS Score
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 3-8 : severe
head injury
 9-12 : moderate
head injury
 13-15 : mild head
injury
 Cont
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 Same priority to adult,

pediatric, pregnant mother.
 Main assessment:
 A : airway with C-spine and
arterial
 B : breathing
 C : circulation
 D : disability
 E : exposure /
environment / examination
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Airway with C-Spine & arterial
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 Any difficulty in breathing  Adakah kesulitan bernapas

karena obstruksi jalan
due to airway obstruction? napas?
 “Look, listen & feel” for - "Lihat, dengarkan &
rasakan" untuk bernafas
breathing - Identifikasi tanda & gejala
 Identify sign & symptoms obstruksi jalan napas:
for airway obstruction: -- stridor
-- Gasping/terengah-engah
 Stridor -- wheezing/Mengi
 Gasping Dll
 Wheezing
 Etc
 Cont.
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 Identify cause of airway
obstruction:
 dentures / vomits / tongue
falls back.
 Ways of clearing – finger
sweeps / suctioning
 Oral / nasal pharyngeal airway
 Positions: Jaw Thrust
 Identifikasi penyebab
obstruksi jalan napas:
- gigi palsu / muntah / lidah
jatuh kembali.
 Cara membersihkan –
sapuan jari / penyedotan
 Oral/nasal pharyngeal airway
 Posisi: Jaw Thrust
 Cont
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 ? C-spine injury
 Those who with head
injury, falls, abuse,
assault.
 ? C-cedera tulang
belakang
 Mereka yang mengalami
cedera kepala, jatuh,
pelecehan, penyerangan.
 Cont
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To prevent further damage:

Cervical collar

Spinal board

Head immobilizer

Untuk mencegah
kerusakan lebih lanjut:
Kerah serviks

Papan tulang belakang

Immobilizer kepala
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 Breathing
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 Is the client having  Apakah klien mengalami distres

respiratory distress? pernapasan?
 Observe for: Perhatikan untuk:
 Rate, rhythm, volumn - Tingkat, ritme, volume
 Usage of accessory
- Penggunaan otot bantu
muscles
 Chest expansion - Ekspansi dada

 Skin color - Warna kulit

 Chest auscultation
 Auskultasi dada
 Listen for noise
 Dengarkan kebisingan
 Oxygen or ventilation 
as required Oksigen atau ventilasi sesuai
kebutuhan
 Face mask  Topeng wajah
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 Circulation
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 Is the client having signs and 
symptoms of decrease
cardiac out put and disturb
organ perfusion?
 Mental status
 Heart rate & rhythm
 Pulse rate & rhythm (radial vs
carotid)
 BP
 Skin color & temperature
 Capillary refill time
Apakah klien mengalami
tanda dan gejala penurunan
curah jantung dan gangguan
perfusi organ?
- Status mental
- Detak jantung & ritme
- Denyut nadi & irama (radial
vs karotis)
- BP
- Warna & suhu kulit
- Waktu pengisian kapiler
 Cont
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 Intervention:
 Feel for pulse
 Look for and treat the life
threatening wound
 Intravenous access
 Intervensi:
 Rasakan denyut nadi
 Cari dan obati luka yang
mengancam nyawa
 Akses intravena
 Cont
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 Are there signs & symptoms of

arterial bleeding?
 Emerges in spurts
 Bright red
 Uncontrolled amount
 Difficult to stop

 Apakah ada tanda & gejala

perdarahan arteri?
- Muncul dalam semburan
- Merah terang
- Jumlah yang tidak terkontrol
- Sulit dihentikan
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 Disability
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 Is the client’s neurological status

disturbed?
 GCS
 Verbal response
 Motor response to pain/stimuli
 Pupil size & reaction to light

 Apakah status neurologis klien

terganggu?
 GCS
- Respon verbal
- Respon motorik terhadap
nyeri/rangsangan
- Ukuran pupil & reaksi terhadap
cahaya
 Cont
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 Is the clients blood  Apakah suplai darah

and nerve supply dan saraf klien
disturbed? terganggu?
 Observe for  Amati perubahan

neurovascular neurovaskular:
changes: - Warna, suhu nadi, tes
 Color, temperature sensorik untuk
pulse, sensory test to mengetahui kelainan.
determine
abnormalities.
 Cont
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 6 P’s
 Pain
 Pallor
 Pulselessness
 Paresthesia
 Poikilothermia
 Paralysis
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Examine client’s whole body

Remember DCAP – BTLS

DCAP
 D : deformity

 C : contusion / crepitus

 A : abrasion

 P : puncture
 Cont
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BTLS
 B : bruising /

bleeding
 T : tenderness

 L : laceration

 S : swelling
 Re-assessment / evaluation
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 Secondary survey is
carried out when:  Survei sekunder
 Primary survey is dilakukan pada saat:
completed - Survei utama selesai
 ABCDEs are re- - BCDE dievaluasi ulang
evaluated - Tanda-tanda vital
kembali normal.
 Vital signs back to
normal.
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 Secondary survey
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 A systematic  Penilaian yang sistematis

assessment  Lebih detail dan fokus
 More detail and focus pada riwayat
to history of the cedera/penyakit saat ini.
present injury /  Dilakukan setelah
diseases. kondisi yang mengancam
 Carried out once life jiwa teratasi.
threatening condition
overcome.
 Cont
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 Main component:  Komponen utama:

 History - Sejarah
 Physical examination - Pemeriksaan fisik
 Complete neurological - Pemeriksaan neurologis
examination
lengkap
 Diagnostic
investigation
- Investigasi diagnostik
 Evaluation / - Evaluasi / penilaian
reassessment. ulang
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 History
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 A : Alergi
 A Allergies  M: Obat-
obatan
 M Medications  P Penyakit
masa lalu
 P Past illnesses  L Makan
 L Last meal terakhir
 E acara /
 E event / lingkungan
environtment
 Cont
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 Identify complains from  Identifikasi keluhan dari

client and priorities them. klien dan prioritaskan.
 Identifikasi mekanisme
 Identify mechanism of cedera untuk
injury to give sign of memberikan tanda
index of suspicious indeks kecurigaan
toward injury. terhadap cedera.
 Sejauh mana cedera itu
 How far is the injury was diduga.
suspected.
 Mechanism of Injury
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 Client able to:

 Identify the force lead to injury
 Explain type of injury
 Identify other possible injury

 Klien mampu:
- Identifikasi kekuatan yang
menyebabkan cedera
- Jelaskan jenis cedera
- Identifikasi kemungkinan
cedera lainnya
 History :Identify types of trauma
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 Penetrating trauma
 Due to insertion of an
object into skin, internal
organ
 eg: stab wound, gun shot

 Trauma tembus
- Karena penyisipan suatu
benda ke dalam kulit, organ
dalam
- contoh: luka tusuk, tembakan
senjata
 Cont
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 Crushed trauma
 fleshy, ruptured blood
vessels & nerves
 Eg : bombed; earth
quake
 Trauma yang hancur
- berdaging, pembuluh
darah & saraf pecah
- Misal : dibom; gempa
bumi
 History :Identify types of trauma
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 Acceleration & deceleration

wound
 Happen when body immediately
stop from very fast movement
 Eg: drive very fast & hit tree

 Luka akselerasi & deselerasi

- Terjadi ketika tubuh langsung
berhenti dari gerakan yang sangat
cepat
-Misalnya: mengemudi sangat cepat
& menabrak pohon
 Cont
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 Thermal injury
 tissues damage due to heat,
fire or chemical
 Exp : burn, frostbite, sunburn,
radiation etc.

 Cedera termal
-kerusakan jaringan karena
panas, api atau bahan kimia
-Contoh : luka bakar, radang
dingin, terbakar sinar
matahari, radiasi dll.
 History : assess c/o pain
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 L locasion
 O onset
 P provoke
 Q quality
 R radiation
 S severity
 T time
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 Head Inspection
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 GCS score  skor GCS

 Neurological  Penilaian
assessment neurologis
 Pemeriksaan
 Comprehensive eye/ear mata/telinga yang
exams komprehensif
 Pitfalls / difficulty:  Kesulitan /
kesulitan:
 Unconscious client - Klien tidak sadar
 Periorbital edema - Edema periorbita
 Occluded auditory - Pendengaran
tertutup
 Maxillofacial Examination
Pemeriksaan Maksilofasial
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 Bony crepitus /
stability  Krepitasi tulang /
stabilitas
 Palpable deformity  Deformitas teraba
 Pitfalls:  Jebakan:
- Resiko obstruksi jalan
 Risk for airway
nafas
obstruction - Fraktur pelat
 Cribiform plate cribriform
fracture
 Cervical Spine
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 Palpate for tenderness

 Complete motor /
sensory exams
 Palpasi untuk
 Reflexes kelembutan
 Lengkapi pemeriksaan
 S-Spine imaging motorik / sensorik
 Pitfalls:  Refleks
 Pencitraan S-Spine
 Altered LOC for any  Jebakan:
reasons - Mengubah LOC karena
alasan apa pun
 Other painful injuries. - Cedera menyakitkan
lainnya.
 Neck (soft tissues)
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 Mechanism : Blunt vs penetrating

 airway obstruction
 hoarseness
 Haematoma
 Stridor

 Mekanisme : Tumpul vs tembus

 obstruksi jalan napas
 suara serak
 hematom
 stridor
 Cont
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 Bruit
 Pitfalls
 Delayed symptoms & signs

 Progressive airway

obstruction
 Occult injuries.

 Kabar angin
 Jebakan
- Gejala & tanda yang tertunda
- Obstruksi jalan napas progresif
- Cedera okultisme.
 Chest
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 Inspect
 Memeriksa
 Palpate  Meraba
 Auscaltation  Auskultasi
 Radiografi
 Radiographs  Batu
 Pit fall sandungan
 Elderly - Tua
 children - anak-anak
 Abdominal Evaluation
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 Inspect, auscultate, palpate and

percuss
 Re-evaluate frequently
 Special studies
 Pitfall
 Hollow viscous and retroperitoneal
injuries, excessive pelvic.
 Inspeksi, auskultasi, palpasi dan
perkusi
 Evaluasi ulang sering
 Studi khusus
 Batu sandungan
- Cedera viskos dan retroperitoneal
berongga, panggul berlebihan.
 Perineum
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 Perineum
 Contusions,  Perineum
- Kontusio,
haematomas, hematoma,
laceration, urethral laserasi, darah
blood uretra
 Rectum  Dubur
 Sphincter-tone, high- - Tonus sfingter,
riding postate, pelvic prostat yang
fracture, rectal wall menunggangi
integrity. tinggi, fraktur
panggul, integritas
dinding rektum.
 Cont
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 Vagina:
 Blood, lacerations

 Pitfall:
 Urethral injury in

women, pregnancy.
 Vagina:
- Darah, laserasi
 Batu sandungan:

- Cedera uretra pada

wanita, kehamilan
 Musculoskeletal & Extremities
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 Contusion, deformity
 Pain Memar,
 Perfusion deformitas
 Peripheral Nyeri
neurovascular status Perfusi
Status
 Radiographs as neurovaskular
required perifer\
Radiografi sesuai
kebutuhan
 Musculoskeletal : Pelvic
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 Pain on palpation
 Simphysis width Nyeri pada
 Leg length uneven palpasi
(not equal) Lebar simfisis
Panjang kaki
 Instability
tidak rata (tidak
 Radiographs PRN sama)
Ketidakstabilan
Radiografi PRN
55

 Pitfalls:
 Risk for blood loss
 Jebakan:
 Missed fracture
- Resiko kehilangan darah
 Soft tissues or - Fraktur yang terlewatkan
ligamentous injury - Jaringan lunak atau
cedera ligamen
 Occult compartment
- Sindrom kompartemen
syndrome (especially tersembunyi (terutama
with altered dengan perubahan
LOC/hypotension) LOC/hipotensi)
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 Neurological examination
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 Complete motor &

sensory exams  Lengkapi pemeriksaan
 Imaging as indicated motorik & sensorik
 Pencitraan seperti yang
 Reflexes
ditunjukkan
 CNS:  Refleks
 Frequent re-evaluation  SSP:
 Prevent secondary brain
- Evaluasi ulang yang
sering
injury - Mencegah cedera otak
 Early neurosurgical sekunder
consultation - Konsultasi bedah saraf
awal
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 Pitfalls:  Jebakan:
 Incomplete - Imobilisasi tidak
immobilization lengkap
 Rapid deterioration - Kerusakan yang cepat
 Subtle increase in
- Peningkatan halus
intra-cranial pressure dalam tekanan intra-
with manipulation kranial dengan
manipulasi
Note:
1. The GCS should be scored on the client’s best responses.

2. The GCS may be falsely law if one of the following is present:

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 Shock, hypoxia, hypothermia, intoxication, sedative drug

administration
3. The GCS may be impossible to evaluate accurately if the client is

agitated, un-cooperative, dysphasic, intubated or hasesignificant

facial or spinal cord injuries.
Catatan:
1. GCS harus dinilai berdasarkan respons terbaik klien.

2. GCS mungkin salah hukum jika salah satu dari berikut ini hadir:

- Syok, hipoksia, hipotermia, intoksikasi, pemberian obat penenang

3. GCS mungkin tidak mungkin untuk dievaluasi secara akurat jika

klien gelisah, tidak kooperatif, disfasik, diintubasi atau memiliki
cedera wajah atau medula spinalis yang signifikan.
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 Re-evaluation
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 Minimizing missed
injuries
 Meminimalkan cedera
 High index of yang terlewatkan
suspicion  Indeks kecurigaan
 Frequent re-evaluation yang tinggi
 Evaluasi ulang dan
and monitoring pemantauan yang
 Some injuries can be sering
seen / can be seen - Beberapa luka dapat
earlier. dilihat/dapat dilihat
sebelumnya.
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 TERTIARY SURVEY
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 Comprehensive
examination
 Thoroughly done after  Pemeriksaan
secondary survey komprehensif
 Normally client is  Benar-benar dilakukan
already admitted. setelah survei sekunder
 Biasanya klien sudah
diterima.
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