Prinsip Primary Survey
Prinsip Primary Survey
Prinsip Primary Survey
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,
gurglingada darah/cairan, snoringobstruksi
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 :
Mengorokchin lift, jaw thrust
Gurglingsuction , 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 lemahsyok
bila ada perdarahan luarhentikan 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?”
History of illness
SAMPLE History
OPQRST
MECHANISM OF INJURY
MOI
NOI
Nature of Illness
SAMPLE
S – Signs and P – Pertinent History
Symptoms
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