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    Prinsip Primary Survey

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    TRI WAHYUNINGSIH
    The document discusses the process of primary and secondary patient assessment for trauma patients. It covers assessing the airway, breathing, circulation, disability, and exposure during primary survey. Key steps include evaluating breathing sounds, circulation by feeling pulses and skin temperature, neurological status, and looking for injuries. The secondary survey involves a full physical exam and getting the patient history. Nursing diagnoses are then made based on findings and interventions are implemented and evaluated.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Prinsip Primary Survey

    Uploaded by

    TRI WAHYUNINGSIH
    184 views41 pages
    The document discusses the process of primary and secondary patient assessment for trauma patients. It covers assessing the airway, breathing, circulation, disability, and exposure during primary survey. Key steps include evaluating breathing sounds, circulation by feeling pulses and skin temperature, neurological status, and looking for injuries. The secondary survey involves a full physical exam and getting the patient history. Nursing diagnoses are then made based on findings and interventions are implemented and evaluated.

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    The document discusses the process of primary and secondary patient assessment for trauma patients. It covers assessing the airway, breathing, circulation, disability, and exposure during primary survey. Key steps include evaluating breathing sounds, circulation by feeling pulses and skin temperature, neurological status, and looking for injuries. The secondary survey involves a full physical exam and getting the patient history. Nursing diagnoses are then made based on findings and interventions are implemented and evaluated.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    184 views41 pages

    Prinsip Primary Survey

    Uploaded by

    TRI WAHYUNINGSIH
    The document discusses the process of primary and secondary patient assessment for trauma patients. It covers assessing the airway, breathing, circulation, disability, and exposure during primary survey. Key steps include evaluating breathing sounds, circulation by feeling pulses and skin temperature, neurological status, and looking for injuries. The secondary survey involves a full physical exam and getting the patient history. Nursing diagnoses are then made based on findings and interventions are implemented and evaluated.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 41

    Imron Rosyadi,Skep,Ns

    Pengkajian
     Pengkajian Primer / primary survey
     Pengkajian Sekunder / scondary survey
    Pengkajian Primer
     Airway
     Breathing
     Circulation
     Dissability
     Expossure
    A: Airway
     Look, listen dilakukan dg C spine control
    Look : apakah ada nafas, apakah ada sumbatan ?,
    tanda-tanda hypoksia, tanda cianosis ?
    Listen : mengorok  lidah jatuh ke belakang,
    gurglingada darah/cairan, snoringobstruksi
    parsial faring / laring
    Feel : rasakan adanya hembusan udara ekspirasi,
    tentukan apakah trakhea terletak di tengah
    sumbatan total

    sumbatan parsial
    A : Airway
     Bila ditemukan ada masalah langsung dilakukan
    tindakan :
     Mengorokchin lift, jaw thrust
     Gurglingsuction , teknik sapuan jari bila ada
    kotoran makanan
     Stridor  pada kasus ps kebakaran dg udem laryng
    pertimbangkan pemasangan ET
     Bebaskan jalan nafas ekstensi head tilt
     Pada pasien trauma curiga adanya fraktur servikal
    tdk boleh dilakukan head tilt, cukup chin lift, jaw
    thrust
    head tilt
    look,feel,listen

    jaw thrust
    manuver
    head tilt
    Pasien yang dicurigai fraktur
    servikal
     Trauma dengan penurunan kesadaran
     Luka karena trauma tumpul diatas klavikula > dari 2
    jejas
     Setiap multi trauma ( trauma pada 2 regio atau lebih )
     Riwayat biomekanika yang mendukung
    B : Breathing
     Kaji nafas  bila tdk ada nafas ventilasi/nafas
    bantuan
     Hitung Respirasi Rate
     Kaji kesimetrisan pergerakan dinding dada
     Kaji adanya jejas : luka tumpul, luka tajam
     Kaji bunyi nafas kanan kiri
     Perkusi dinding dada kanan kiri
    C : Circulation
     bagaimana perfusi pasien
     akral hangat / dingin ? dingin awas syok!!
     raba nadi : carotis,femoralis  tdk teraba kompresi
    dada, nadi cepat dan lemahsyok
     bila ada perdarahan luarhentikan perdarahan
    balut tekan
     pasien shock  pasang IV line, ambil sampel darah
    D : Dissability
     kaji tingkat kesadaran  AVPU
     kaji adanya lateralisasi  diameter pupil, kekuatan
    menggenggam kanan kiri
     kaji adanya tanda-tanda fraktur
     kaji adanya kelemahan, kesemutan,sensasi yang
    berkurang pada ekstremitas
    AVPU
     A – Alert

     V – Verbal

     P – Responds to Pain

     U – Unresponsive
    E. Exposure
     Lihat seluruh tubuh pasien
     Pasien “ditelanjangi”  jaga jangan sampai
    kedinginan  selimut
     cari adanya luka , jejas
    Pengkajian Sekunder
     Tingkat kesadaran  GCS
     Tanda Vital : TD,R,N,SB
     Riwayat Kesehatan  RPS, RPD  anamnesa
     Pemeriksaan fisik
    Pengkajian Riwayat Kesehatan
     Keluhan Utama ? Chief Complaint
     Riwayat Penyakit
    Chief Complaint
     “What’s wrong?” “What happened to you?”

     Usually, the patient reports the major signs and


    symptoms when asked these questions
    Focused History and Physical Exam

     History of illness

     SAMPLE History

     OPQRST
    MECHANISM OF INJURY
    MOI
    NOI
    Nature of Illness
    SAMPLE
     S – Signs and  P – Pertinent History
    Symptoms

     A – Allergies  L – Last Oral Intake

     M - Medications  E – Events Prior


    OPQRST
     O – Onset
     R – Radiation

     P – Provocation  S – Severity

     Q - Quality  Time
    Pemeriksaan Fisik
     Head to toe
     Mencari adanya kelainan
    DCAP-BTLS
     D – Deformities  B – Bleeding – Burns

     C – Contusions  T – Tenderness

     A – Abrasions  L – Lacerations

     P - Punctures  Swelling
    CMS
     Circulation

     Motion

     Sensation
    Assess the Head
     Look and feel for
    DCAP-BTLS and
    crepitus
     Look for fluid in ears
     Pupils
     Loose teeth or dental
    appliances
     Palpate the zygomas
    and maxillae
     Palpate the mandible
     Assess the mouth
     Look at the neck and
    palpate front and rear
    Assess the Neck
     Look and feel for
    DCAP-BTLS, jugular
    vein distention, and
    crepitus
     Stoma
    Assess the Chest
     Look and feel for
    DECAP-BTLS,
    paradoxical motion,
    and crepitus.
     Medical Alert Tag
     Look at the chest
     Palpate ribs
     Breath sounds?
     Assess breath
    sounds.
    Assess the Abdomen
     Look and feel for
    DCAP-BTLS, rigidity
    (Firm or Soft), and
    distention or pain
     Look at the abdomen
    and pelvis
     Palpate the abdomen
     Compress the pelvis
     Press the iliac crests
     Assess the lower
    extremities
     Distal and CMS
    Assess the Pelvis
     Look and feel for
    DCAP-BTLS. If there
    is no pain, gently
    compress the pelvis
    downward and
    inward to determine
    tenderness or
    instability.
    Assess the Extremities
     Palpate each leg
    completely, from the hip
    to the foot. Remember
    CMS
     Palpate each arm from
    the shoulder to each
    hand. Remember CMS

     Palpate gently but


    firmly. You cannot
    palpate with a pat down!
     Assess the upper
    extremities
     Distal pulse – CMS
     Medical Alerts
     Assess the back for
    deformity or
    tenderness
    Assess the Back
     Roll the patient using spinal precautions, to assess the
    posterior aspects of he bodyLog Roll
     DCAP-BTLS
    Ongoing Assessment
     Monitor for possible changes in a patients condition.
     Repeat the Initial Assessment
     Continue to assess vital signs
     Repeat Focused Assessment
     Check Interventions
     Record findings
    Diagnosis Keperawatan
     Berdasarkan temuan  analisa data  diagnosis
    keperawatan
     Muncul Masalah Kolaborasi
     Diagnosis Keperawatan sesuai NANDA
    Diagnosis Keperawatan
     Risiko aspirasi
     Tidak efektifnya jalan nafas
     Gangguan pola nafas
     Gangguan pertukaran gas
     Penurunan curah jantung
     Perubahan perfusi jaringan ; serebral,ginjal..
     Cemas
     dll
    Masalah kolaborasi
     PK: Syok hypovolemia
     PK: Syok kardiogenik
     PK: Perdarahan
     PK: Anemia
     PK: Sepsis
     dll
    Intervensi keperawatan
     untuk mengatasi masalah
     intervensi berdasar protokol / prosedur tetap
     intervensi mandiri
     intervensi kolaborasi
    Evaluasi
     untuk mengevaluasi kondisi pasien
     untuk menilai efektivitas tindakan
     dilakukan setiap 5 menit, 15 menit, 30 menit
     untuk menentukan intervensi selanjutnya
     untuk menentukan perawatan selanjutnya

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