Skala Koma Glasgow

The Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way
of recording the conscious state of a person for initial as well as subsequent assessment. A patient is
assessed against the criteria of the scale, and the resulting points give a patient score between 3
(indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used
modified or revised scale).
GCS was initially used to assess level of consciousness after head injury, and the scale is now used
by first aid, EMS, nurses and doctors as being applicable to all acute medical and trauma patients. In
hospitals it is also used in monitoring chronic patients in intensive care.

Unsur Skala Koma Glasgow

1

Eye

Does not
open eyes

Opens eyes in
response to painful
stimuli

Opens eyes in
response to
voice

Opens eyes
spontaneously

N/A

N/A

Verbal

Makes no
sounds

Incomprehensible
sounds

Utters
inappropriate
words

Confused,
disoriented

Oriented,
converses
normally

N/A

Makes no
movements

Extension to painful
stimuli (decerebrate
response)

Abnormal
flexion to
painful stimuli
(decorticate
response)

Flexion /
Withdrawal to
painful stimuli

Localizes
painful
stimuli

Obeys
commands

Motor

Eye response (E)

There are four grades starting with the most severe:
1. No eye opening
2. Eye opening in response to pain stimulus. (a peripheral pain stimulus,
such as squeezing the lunula area of the patient's fingernail is more
effective than a central stimulus such as a trapezius squeeze, due to a
grimacing effect).[3]
3. Eye opening to speech. (Not to be confused with the awakening of a
sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously
Verbal response (V)
There are five grades starting with the most severe:
1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)

3. Inappropriate words. (Random or exclamatory articulated speech, but

no conversational exchange. Speaks words but no sentences.)
4. Confused. (The patient responds to questions coherently but there is
some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions
such as the patients name and age, where they are and why, the
year, month, etc.)
Motor response (M)
There are six grades:
1. No motor response
2. Decerebrate posturing accentuated by pain (extensor
response: adduction of arm, internal rotation of shoulder, pronation of
forearm and extension at elbow, flexion of wrist and fingers, leg
extension, plantarflexion of foot)
3. Decorticate posturing accentuated by pain (flexor response: internal
rotation of shoulder, flexion of forearm and wrist with clenched fist, leg
extension, plantarflexion of foot)
4. Withdrawal from pain (Absence of abnormal posturing; unable to lift
hand past chin with supra-orbital pain but does pull away when
nailbed is pinched)
5. Localizes to pain (Purposeful movements towards painful stimuli; e.g.,
brings hand up beyond chin when supra-orbital pressure applied.)
6. Obeys commands (The patient does simple things as asked.)
Nasal cannula
The nasal cannula (NC) is a device used to deliver supplemental oxygen or
airflow to a patient or person in need of respiratory help. This device consists
of a light weight tube which on one end splits into two prongs which are
placed in the nostrils and from which a mixture of air and oxygen flows. The
other end of the tube is connected to an oxygen supply such as a portable
oxygen generator, or a wall connection in a hospital via a flow meter. The
cannula is generally attached to the patient by way of the tube hooking
around the patient's ears or by elastic head band. The earliest, and most
widely used form of adult nasal cannula carries 15 litres of oxygen per
minute. Cannulae with smaller prongs intended for infant or neonatal use can
carry less than one litre per minute. Flow rates of up to 60 litres of air/oxygen
per minute can be delivered through wider bore humidified nasal cannula.

The nasal cannula was invented by Wilfred Jones

and patented in 1949 by his employer, BOC.
Supplemental oxygen
A nasal cannula is generally used wherever
small amounts of supplemental oxygen are
required, without rigid control of respiration,
such as in oxygen therapy. Most cannulas can
only provide oxygen at low flow ratesup to 5
liters per minute (L/min)delivering an oxygen
concentration of 2844%. Rates above 5
L/min can result in discomfort to the
patient, drying of the nasal passages, and
possibly nose bleeds (epistaxis). Also with
flow rates above 6 L/min, the laminar flow becomes turbulent and the
oxygen therapy being delivered is only as effective as delivering 5-6 L/min.

FACE MASK

1. Simple face mask

The simple face mask (SFM) is a basic disposable mask, made of clear
plastic, to provide oxygen therapy for patients who are experiencing
conditions such as chest pain(possible heart attacks), dizziness, and
minor hemorrhages. It is often set to deliver oxygen between 6-10
litres per minute. This mask is only meant for patients who are
able to breathe on their own, but who may require a higher
oxygen concentration than the 21% concentration found in
ambient air. Patients who are unable to breathe on their own are
placed on a medical ventilator instead.
The final oxygen concentration delivered by a simple face mask is
dependent upon the amount of room air that mixes with the oxygen the
patient breathes. The air mixing is determined by how much air any
individual is breathing at the moment, combined with the fit of the mask.
Because of the variability in these factors, the final oxygen concentration
is uncontrolled. A venturi device attached to the mask can be used to
control to some degree the concentration of oxygen delivered, usually this
is used to prevent respiratory depression in emphysema patients who
have lost the ability to fully inhale. The effectiveness of the therapy can
be continuously monitored using a pulse oximeter, though more clinically
useful data can only by obtained by drawing arterial blood gas.
2. Rebreather mask
A rebreather mask has a soft plastic reservoir bag attached at the end
that saves one-third of a persons exhaled air, while the rest of the air
gets out via side ports covered with a one-way valve. This allows the
person to rebreathe some of the carbon dioxide, which acts as
a way to stimulate breathing.
3. Non-rebreather mask
A non-rebreather mask, or NRB, is a device used in medical
emergencies that requires oxygen therapy. An NRB requires that the
patient can breathe unassisted, but unlike low flow nasal cannula, the
NRB allows for the delivery of higher concentrations of oxygen.

Design
The non-rebreather mask covers both the nose and mouth of the patient
and attaches with the use of an elastic cord around the patient's head.
The NRB has an attached reservoir bag, typically 1 liter, that connects to
an external oxygen tank or Bulk Oxygen Supply system. Before an NRB is
placed on the patient, the reservoir bag is inflated to greater than twothirds full of oxygen, at a rate of 15 liters per minute (lpm). Approximately
of the air from the reservoir is depleted as the patient inhales, and it is
then replaced by the flow from the O2 supply. If the bag becomes
completely deflated, the patient will no longer have a source of air to
breathe.
Exhaled air is directed through a one-way valve in the mask, which
prevents the inhalation of room air and the re-inhalation of exhaled air.
The valve, along with a sufficient seal around the patient's nose and
mouth, allows for the administration of high concentrations of oxygen,
approximately 60%-80% O2. Many textbooks report higher oxygen
concentrations, however formal studies reporting these levels are not
referenced to research. The patient must partially deflate the reservoir
bag during inspiration or the high oxygen concentration will not be
achieved, and the mask will provide only the liter flow rate setting on the
flowmeter.
4. Venturi mask
The venturi mask, also known as an air-entrainment mask (and
sometimes by the brand name Ventimask), is a medical device to
deliver
a
known oxygen concentration
to
patients
on
controlled oxygen therapy. The mask was invented by Moran
Campbell as a replacement for intermittent oxygen treatment, a practice
he described as "bringing a drowning man to the surface- occasionally".
Venturi masks are considered high-flow oxygen therapy devices. This is
because venturi masks are able to provide total inspiratory flow at a
specified FiO2 to patients therapy. The kits usually include multiple jets in
order to set the desired FiO2 which are usually color-coded.
Other brands of masks have a rotating attachment that controls the air
entrainment window, affecting the concentration of oxygen. This system
is often used with air-entrainment nebulizers to provide humidification and
oxygen therapy.
Mechanism
The mechanism of action is usually incorrectly quoted as depending on
the venturi effect. Despite there being no evidence for this, many
textbooks and journal articles cite this as the mechanism. However, a
fixed performance oxygen delivery system, despite often being called a
venturi mask works on the principle of jet mixing. [1] [2]
Use
Delivering supplemental oxygen at a precise concentration.

Flow problems
Air entrainment masks, although considered high flow systems, are not
always able to guarantee the total flow with oxygen percentages above
35% in patients with high inspiratory flow demands. The problem with air
entrainment systems is that as the FiO2 is increased, the air to oxygen
ratio decreases. For example, for 30% the ratio is 8 parts air to 1 part
oxygen.
For 40% the ratio decreases to 3 to 1. Since the jets in venturi masks
generally limit oxygen flow at 12 to 15 liters per minute the total flow
decreases as the ratio decreases.
At an oxygen flow rate of 12 liters per minute and a 30% FiO2 setting, the
total flow would be 108 L/min. At a 40% FiO2 setting, the total flow would
decrease to 48 L/min.
As a rule of thumb, 60 L/min is considered the minimum flow rate to
qualify as a high flow device.
Medical ventilator
A medical ventilator (or simply ventilator in
context) is a machine designed to mechanically
move breathable air into and out of the lungs, to
provide the mechanism of breathing for a
patient who is physically unable to breathe, or
breathing insufficiently.
While modern ventilators are computerized
machines, patients can be ventilated with a bag
valve mask, a simple hand-operated bag-valve
mask.
Ventilators are chiefly used in intensive care
medicine, home care, and emergency
medicine (as standalone units) and
in anesthesia (as a component of an anesthesia machine).
Medical ventilators are sometimes colloquially called "respirators," a term
which stems from commonly used devices in the 1950s (particularly the "Bird
Respirator"). However, in modern hospital and medical terminology, these
machines are never referred to as respirators, and use of "respirator" in this
context is now a deprecated anachronism which signals technical
unfamiliarity.
Function
In its simplest form, a modern positive pressure ventilator consists of a
compressible air reservoir or turbine, air and oxygen supplies, a set of valves
and tubes, and a disposable or reusable "patient circuit". The air reservoir is
pneumatically compressed several times a minute to deliver room-air, or in

most cases, an air/oxygen mixture to the patient. If a turbine is used, the

turbine pushes air through the ventilator, with a flow valve adjusting
pressure to meet patient-specific parameters. When overpressure is
released, the patient will exhale passively due to the lungs' elasticity, the
exhaled air being released usually through a one-way valve within the
patient circuit called the patient manifold. The oxygen content of the inspired
gas can be set from 21 percent (ambient air) to 100 percent (pure oxygen).
Pressure and flow characteristics can be set mechanically or electronically.

Life-critical system
Because the failure of a mechanical ventilation system may result in death, it
is classed as a life-critical system, and precautions must be taken to ensure
that mechanical ventilation systems are highly reliable. This includes
their power-supply provision.

Endotracheal Tubes

A tracheal tube is a catheter that is inserted into the trachea for the
primary purpose of establishing and maintaining a patent airway and to
ensure the adequate exchange of oxygen and carbon dioxide.
Many different types of tracheal tubes are available, suited for different
specific applications:

An endotracheal tube is a specific type of tracheal tube that is nearly

always inserted through the mouth (orotracheal) or nose (nasotracheal).

A tracheostomy tube is another type of tracheal tube; this 23-inchlong (5176 mm) curved metal or plastic tube may be inserted into a
tracheostomy stoma (following a tracheotomy) to maintain a patent
lumen.

A tracheal button is a rigid plastic cannula about 1 inch in length that

can be placed into the tracheostomy after removal of a tracheostomy
tube to maintain patency of the lumen.
Applications

Tracheal tubes can also be used to deliver oxygen in higher concentrations

than found in air, or to administer other gases such as helium, nitric
oxide, nitrous oxide, xenon, or certain volatile anesthetic agents such
as desflurane, isoflurane, or sevoflurane. Tracheal tubes may also be used as
a route for administration of certain medications such
assalbutamol, atropine, epinephrine, ipratropium, and lidocaine. Tracheal
tubes are commonly used for airway management in the settings of general
anesthesia, critical care,mechanical ventilation, and emergency medicine.

Radial artery puncture

Radial artery puncture is a medical procedure
performed to obtain a sample of
arterial blood for gas analysis. A needle is
inserted into the radial artery and
spontaneously fills with blood. The syringe is
either prepacked with a small amount
of heparin to prevent coagulation, or must
beheparinised, by drawing up a small amount
of heparin and squirting it out again.
Most commonly, radial artery puncture is
performed to obtain arterial blood sampling for
gas analysis. The partial pressures of oxygen
(PaO2) and carbon dioxide (PaCO2), and the pH
of arterial blood are important in assessing pulmonary function. These data
indicate the status of gas exchange between lungs and blood.
Allen test
It is important to perform an Allen Test to confirm the patency of the
ulnar arterybecause, with no collateral flow through the ulnar
artery, radial artery puncture can result in a gangrenous finger or
loss of the hand from spasm or clotting of the radial artery. The Allen
Test is performed with the patient sitting with hands resting on knees. A
medical professional stands at the patient's side with fingers around the
patient's wrist and compresses the tissue over both radial and ulnar arteries
for a few minuteswaiting for the blood to drain from the hand while the
patient opens and closes the hand several times. Releasing pressure on the
ulnar artery while keeping the radial artery occluded should return normal
skin color to the ulnar side of the palm in one to two seconds, followed by
quick restoration of normal color to the entire palm. A hand that remains

white indicates either absence or occlusion of the ulnar artery, and radial
artery puncture is contraindicated.

Venipuncture
In medicine, venipuncture,
venipuncture or venipuncture is the
process of obtaining intravenous access for
the purpose of intravenous therapy or
for blood sampling of venous blood. This
procedure is performed by medical
laboratory scientists, medical practitioners,
some EMTs, paramedics, phlebotomists,
dialysis technicians, and other nursing
staff. In veterinary medicine, the procedure is performed
by veterinarians and veterinary technicians. Venipuncture is one of the most
routinely performed invasive procedures and is carried out for any of five
reasons: (1) to obtain blood for diagnostic purposes; (2) to monitor levels of
blood components (Lavery & Ingram 2005); (3) to administer therapeutic
treatments including medications, nutrition, or chemotherapy; (4) to remove
blood due to excess levels of iron or erythrocytes (red blood cells); or (5) to
collect blood for later uses, mainly tranfusion either in the donor or in
another person.

Venipuncture in children
Use of lidocaine iontophoresis is an effective method for reducing
pain and alleviating distress during venipuncture in pediatric
patients. Rapid dermal anesthesia can be achieved by local anesthetic
infiltration, but it may evoke anxiety in children frightened by needles or
distort the skin, making vascular access more difficult and increasing the risk
of needle exposure to health care workers. Dermal anesthesia can also be
achieved without needles by the topical application of local anesthetics or by
lidocaine iontophoresis. By contrast, noninvasive dermal anesthesia can be
established in 515 min without distorting underlying tissues by lidocaine
iontophoresis, where a direct electrical current facilitates dermal penetration

of positively charged lidocaine molecules when placed under the positive

electrode.

One study concluded that the iontophoretic administration

of lidocaine was safe and effective in providing dermal anesthesia
for venipuncture in children 617 years old. This technique may not be
applicable to all children. Future studies may provide information on the
minimum effective iontophoretic dose for dermal anesthesia in children and
the comparison of the anesthetic efficacy and satisfaction of lidocaine
iontophoresis with topical anesthetic creams and subcutaneous infiltration. [2]

Subcutaneous injection
A subcutaneous injection is administered as
a bolus into the subcutis,[1] the layer of skin
directly below the dermis and epidermis,
collectively referred to as the cutis.
Subcutaneous injections are highly effective in
administering vaccines and medications such
as insulin, morphine, diacetylmorphine and gose
relin. Subcutaneous, as opposed to intravenous,
injection of recreational drugs is referred to as
"skin popping". Subcutaneous administration
may be abbreviated as SC, SQ, sub-cu, sub-Q, SubQ, or subcut. Subcutis
the preferred abbreviation for patient safety.[2]
Subcutaneous tissue has few blood vessals and so drugs injected here are for
slow, sustained rates of absorption.[3] It is slower than Intramuscular
injections but still faster than intradermal injections.[3]
Procedure[edit]
Subcutaneous injections are inserted at 45 to 90 degree angles, depending
on amount of subcutaneous tissue present and length of needle- a shorter,
3/8" needle is usually inserted 90 degrees and a 5/8" needle is usually
inserted at 45 degrees. Medication is administered slowly, about 10
seconds/milliliter.<Taylor/>

SUARA NAFAS NORMAL

Suara nafas normal dihasilkan dari getaran udara ketika melalui jalan nafas
dari laring ke alveoli, dengan sifat bersih. Suara nafas normal :
a) Bronchial : sering juga disebut dengan Tubular sound karena suara ini
dihasilkan oleh udara yang melalui suatu tube (pipa), suaranya terdengar
keras, nyaring, dengan hembusan yang lembut. Fase ekspirasinya lebih
panjang daripada inspirasi, dan tidak ada henti diantara kedua fase
tersebut. Normal terdengar di atas trachea atau daerah suprasternal
notch.
b) Bronchovesikular : merupakan gabungan dari suara nafas bronchial dan
vesikular. Suaranya terdengar nyaring dan dengan intensitas yang
sedang. Inspirasi sama panjang dengan ekspirasi. Suara ini terdengar di
daerah thoraks dimana bronchi tertutup oleh dinding dada.
c) Vesikular : terdengar lembut, halus, seperti angin sepoi-sepoi. Inspirasi
lebih panjang dari ekspirasi, ekspirasi terdengar seperti tiupan.

SUARA NAFAS TAMBAHAN/ABNORMAL

1.

Crackles
Adalah bunyi yang berlainan, non kontinu akibat penundaan pembukaan
kembali jalan napas yang menutup. Terdengar selama : inspirasi.
Fine crackles/krekels halus
Terdengar selama : akhir inspirasi. Karakter suara : meletup, terpatahpatah.
Penyebab : udara melewati daerah yang lembab di alveoli atau
bronchioles/penutupan jalan napas kecil. Suara seperti rambut yang
digesekkan.
Krekels kasar
Terdengar selama : ekspirasi. Karakter suara : parau, basah, lemah,
kasar, suara gesekan terpotong.
Penyebab : terdapatnya cairan atau sekresi pada jalan nafas yang
besar. Mungkin akan berubah ketika klien batuk.

Wheezing (mengi)
Adalah bunyi seperti bersiul, kontinu, yang durasinya lebih lama dari
krekels. Terdengar selama : Ekspirasi.
Penyebab
:
akibat
udara
melewati
jalan
napas
yang
menyempit/tersumbat sebagian. Dapat dihilangkan dengan batuk.Dengan
karakter suara nyaring, suara terus menerus yang berhubungan dengan
aliran udara melalui jalan nafas yang menyempit (seperti pada asma dan
bronchitis kronik). Wheezing dapat terjadi oleh karena perubahan
temperature, allergen, latihan jasmani, dan bahan iritan terhadap
bronkus.
3. Ronchi
2.

Adalah bunyi gaduh yang dalam. Terdengar selama : ekspirasi.

Penyebab : gerakan udara melewati jalan napas yang menyempit akibat
obstruksi napas. Obstruksi : sumbatan akibat sekresi, odema, atau tumor.
Contoh : suara ngorok.
- Ronchi kering : suatu bunyi tambahan yang terdengar kontinyu
terutama waktu ekspirasi disertai adanya mucus/secret pada bronkus.
Ada yang high pitch (menciut) misalnya pada asma dan low pitch oleh
karena secret yang meningkat pada bronkus yang besar yang dapat
juga terdengar waktu inspirasi.
- Ronchi basah (krepitasi) : bunyi tambahan yang terdengar tidak
kontinyu pada waktu inspirasi seperti bunyi ranting kering yang
terbakar, disebabkan oleh secret di dalam alveoli atau bronkiolus.
Ronki basah dapat halus, sedang, dan kasar. Ronki halus dan sedang
dapat disebabkan cairan di alveoli misalnya pada pneumonia dan
edema paru, sedangkan ronki kasar misalnya pada bronkiekstatis.
Perbedaan ronchi dan mengi.
Mengi berasal dari bronki dan bronkiolus yang lebih kecil salurannya,
terdengar bersuara tinggi dan bersiul. Biasanya terdengar jelas pada
pasien asma.
Ronchi berasal dari bronki dan bronkiolus yang lebih besar salurannya,
mempunyai suara yang rendah, sonor. Biasanya terdengar jelas pada
orang ngorok.
4. Pleural friction rub
Adalah suara tambahan yang timbul akibat terjadinya peradangan pada
pleura sehingga permukaan pleura menjadi kasar.
Karakter suara : kasar, berciut, disertai keluhan nyeri pleura. Terdengar
selama : akhir inspirasi dan permulaan ekspirasi. Tidak dapat dihilangkan
dengan dibatukkan. Terdengar sangat baik pada permukaan anterior
lateral bawah toraks.
Terdengar seperti bunyi gesekan jari tangan dengan kuat di dekat telinga,
jelas terdengar pada akhir inspirasi dan permulaan ekspirasi, dan
biasanya disertai juga dengan keluhan nyeri pleura. Bunyi ini dapat
menghilang ketika nafas ditahan. Sering didapatkan pada pneumonia,
infark paru, dan tuberculosis.
Nyeri
Karakteristik nyeri (Metode P, Q, R, S, T).
1. Faktor Pencetus (P: Provocate),
Perawat mengkaji tentang penyebab atau stimulus-stimulus nyeri pada
klien, dalam hal ini perawat juga dapat melakukan observasi bagianbagian tubuh yang mengalami cedera.
2. Kualitas (Q: Quality),
Kualitas nyeri merupakan seseuatu yang subjektif yang diungkapkan oleh
klien. Misal kalimat-kalimat: tajam, tumpul, berdenyut, berpindah-pindah,
seperti tertindih, perih, dan tertusuk.
3. Lokasi (R: Region),

Untuk mengkaji lokasi nyeri maka perawat meminta klien untuk

menunjukkan semua bagian atau daerah yang dirasakan tidak nyaman
oleh klien.
4. Keparahan (S: Severe),
Tingkat keparahan pasien tentang nyeri merupakan karakteristik yang
paling subjektif. Pada pengkajian ini klien diminta untuk menggambarkan
nyeri yang ia rasakan sebagai nyeri ringan, nyeri sedang atau berat.
5. Durasi (T: Time).
Perawat menanyakan pada pasien untuk menentukan awitan, durasi, dan rangkaian nyeri
Untuk
mengukur
skala
intensitas
nyeri
pada
anak-anak
dikembangkan alat yang dinamakan Oucher, yang terdiri dari dua skala
yang terpisah dengan nilai 0-100 pada sisi sebelah kiri untuk anak-anak yang
berusia lebih besar dan skala fotografik enam gambar pada sisi sebelah
kanan yang digunakan pada anak-anak yang lebih kecil.

Gambar 5 Skala Nyeri Wajah yang Dikembangkan Wong & Baker

An arterial blood gas (ABG) is a blood test that is performed using blood from
an artery. It involves puncturing an artery with a thin needle and syringe and
drawing a small volume of blood. The most common puncture site is
the radial artery at the wrist,[1] but sometimes thefemoral artery in
the groin or other sites are used. The blood can also be drawn from
an arterial catheter. Pulse oximetry plus transcutaneous carbon dioxide
measurement is an alternative method of obtaining similar information as
well. An ABG is a test that measures the arterial oxygen
tension (PaO2), carbon dioxide tension (PaCO2), and acidity (pH). In addition,
arterial oxyhemoglobin saturation (SaO2) can be determined. Such
information is vital when caring for patients with critical illness or respiratory
disease. As a result, the ABG is one of the most common tests performed on
patients in intensive care units (ICUs).
Parameters and reference ranges
These are typical reference ranges, although various analysers and
laboratories may employ different ranges.

Analyte

Range

Interpretation

pH

7.34[8]7.44[8]

The pH or H+ indicates if a patient is

acidemic (pH < 7.35; H+ >45) or alkalemic
(pH > 7.45; H+ < 35).

H+

3545
nmol/L(nM)

See above.

Arterialoxygen
partial
pressure(PaO2)

A low PaO2 indicates that the patient is not

oxygenating properly, and is hypoxemic.
(Note that a low PaO2 is not required for
11[9]the patient to have hypoxia.) At a PaO2 of
13[9]kPa or
less than 60 mm Hg, supplemental oxygen
75[8]should be administered. At a PaO2 of less
100[8]mmHg
than 26 mmHg, the patient is at risk of
death and must be oxygenated
immediately.[citation needed]

4.7[9]6.0[9]kPa or
35[8]45[8]mmHg

The carbon dioxide partial pressure

(PaCO2) is an indicator of CO2 production
and elimination: for a constant metabolic
rate, the PaCO2 is determined entirely by
its elimination through ventilation.[10] A
high PaCO2 (respiratory acidosis,
alternatively hypercapnia) indicates
underventilation (or, more rarely,
a hypermetabolic disorder), a low
PaCO2(respiratory alkalosis,
alternatively hypocapnia) hyper- or
overventilation.

HCO3

2226 mEq/
L

The HCO3 ion indicates whether

a metabolic problem is present (such
as ketoacidosis). A low
HCO3 indicatesmetabolic acidosis, a high
HCO3 indicates metabolic alkalosis. As
this value when given with blood gas
results is often calculated by the analyzer,
correlation should be checked with total
CO2 levels as directly measured (see
below).

SBCe

21 to
27 mmol/L

the bicarbonate concentration in the blood

at a CO2 of 5.33 kPa, full oxygen saturation
and 37 Celsius.[11]

Arterialcarbon
dioxide partial
pressure(PaCO2)

Base excess

2 to
+2 mmol/L

The base excess is used for the

assessment of the metabolic component of
acid-base disorders, and indicates whether

the patient has metabolic acidosis or

metabolic alkalosis. Contrasted with the
bicarbonate levels, the base excess is a
calculated value intended to completely
isolate the non-respiratory portion of the
pH change.[12]
There are two calculations for base excess
(extra cellular fluid - BE(ecf); blood BE(b)). The calculation used for the BE(ecf)
= cHCO3 - 24.8 +16.2 X (pH-7.4). The
calculation used for BE(b) = (1-0.014 x
hgb) x (cHCO3 - 24.8 + (1.43 x hgb + 7.7)
x (pH -7.4).
This is the total amount of CO2, and is the
23 sum of HCO3 and PCO2 by the formula:
30[13]mmol/L tCO2 = [HCO3] + *PCO2, where =0.226
or 100[14]mM/kPa, HCO3 is expressed in millimolar
132[14]mg/dL concentration (mM) (mmol/l) and PCO2 is
expressed in kPa [15]
[13]

total CO2(tCO2 (P
)c )

vol% (mL
O2 Content
oxygen/dL
(CaO2, CvO2, CcO2)
blood)

This is the sum of oxygen dissolved in

plasma and chemically bound
to hemoglobin as determined by the
calculation: CaO2 = (PaO2 * 0.003) +
(SaO2 * 1.34 * Hgb) where hemoglobin
concentration is expressed in g/dL.[16]

Menghitung Dosis Obat

Kebanyakan intruksi dan label obat ditulis dalam sitem pengukuran metrik.
Jika jumlah obat spesifik yang dibutuhkan sama dengan jumlah obat yang
tertera dalam label obat, tidak diperlukan perhitungan dosis obat, dan obat
dapat disiapkan dengan cara yang sederhana. Sebagai contoh, jika
kebutuhan dosis ibuprofen 400 mg PO dan di kemasan obat tertulis
ibuprofen 400 mg pertablet ini jelas berarti 1 tablet yang akan diberi.
Tetapi bagaimana jika obat yang dibutuhkan dengan dosis 400 mg, dan obat
yang tersedia tablet dengan dosis 200 mg ? pertanyaannya adalah berapa
banyak 200 mg tablet yang diberikan untuk memenuhi dosis 400 mg? Pada
kasus ini dapat dihitung mudah yaitu 2 tablet. Contoh tersebut merupakan
contoh sedrhana untuk mengilustrasikan perhitungan matematika pada obat.
Masalah tersebut dapat dipecahkan oleh beberapa metode.
Rumus:

D = desired dose dosis yang dinginkan (dosis yang dipesan, biasanya

dalam milligrams)
H = on-hand dosis ditangan atau available dose dosis yang tersedia
(dosis yang tercantum dalam label kemasan biasanya ditulis dalam tablet,
kapsul, atau mililiter)
X = unknown (jumlah obat yang belum diketahui)
V = unit atau satuan (bisa dalam tablet,per mililiter atau cc, dll)

Apa yang terjadi jika permintaan obat dan label obat ditulis dalam unit
(satuan) berbeda? Sebagai contoh, intruksi pemberian obat Amoxicillin 0.5
g dan pada label kemasan tertulis amoxcilin 500 mg/ kapsul untuk
menghitung jumlah kapsul yang sesuai dengan kebutuhan dosis, langkah
pertama adalah merubah 0.5 g ke satuan miligram. Atau merubah 500 mg
ke satuan gram. Dosis yang dinginkan (yang diperintahkan) dan dosis yang
tersedia (atau yang tertulis dalam kemasan) harus dalam satuan ukur yang
sama.
Langkah 1: kita rubah dari gram (g) ke miligram (mg)

Langkah 2: kita hitung menggunakan rumus.

Cara dan rumus yang sama dapat digunakan untuk menghitung dosis obat
dalam bentuk kapsul atau cair. Contohnya sebagai berikut.

b.
d.

b.
d.

Seorang laki-laki usia 23 tahun mengalami kecelakaan bagian frontal membentur jalan,
Saat kejadian sampai saat pengkajian (2 jam post kecelakaan). Pengkajian ditemukan
data: tidak sadarkan diri, pernapasan grugling, nilai GCS: E 2M3V2, saturasi oksigen
87%
Apakah tindakan yang dilakukan perawat pertama kali ?
Suction
Ventilator
Pemasangan OPA
Intubasi (pasang ETT)
Pasang Laringeal Mask Airway
Seorang perempuan berusia 50 tahun dirawat di ruang dewasa mengeluh nyeri kepala,
tidak dapat menelan, tidak merasakan rasa asam, manis dan pahit di lidah bagian
depan, terlihat iritable/gelisah dan ingin tidur terus. Nilai GCS E3V4M5
Apakah prioritas masalah keperawatan pada pasien?
Gangguan persepsi sensori
Gangguan perfusi serebral
Gangguan nutrisi
Resiko jatuh
Nyeri

Seorang perempuan umur 25 tahun dirawat di ruang dewasa karena meningitis. Hasil
pengkajian didapatkan penurunan kesadaran, pernapasan snoring, sesak napas, napas
cepat dan dangkal. Saat anda melakukan hisap lender, perawat menaikan tekanan
oksigen, menghidupkan mesin, mengecek tekanan dan botol penampung,
memasukkan kanul hisap lender ke dalam mulut. Tiba-tiba pasien terbatuk
Apakah tindakan pertama perawat ?
Menghentikan hisap lendir
Menghisap lendir dengan menutup kanul
Mengobservasi keadaan umum dan pernapasan pasien
Mengeluarkan kanul hisap lendir
Mematikan mesin

b.
d.

Seorang laki-laki berusia 46 tahun dirawat di ruang bedah mengeluh sakit pada daerah
punggung setinggi lumbal kebawah setelah mengalami jatuh 2 minggu lalu dari
ketinggian kurang lebih 3 meter dengan posisi jatuh terduduk. Hasil pengkajian sudah
1 minggu pasien tidak dapat mengontrol buang air besar dan buang kecil, lumpuh
pada kedua kaki dan baal/kebas pada daerah kaki bawah kanan dan kiri.
Apakah masalah keperawatan utama pada pasien diatas?
Gangguan pemenuhan aktifitas sehari-hari
Gangguan eleminasi BAB dan BAK
Gangguan persepsi sensori
Gangguan mobilitas fisik
Ganguan integritas kulit
Seorang perempuan berusia 35 tahun, dirawat di ruang penyakit dalam, mengeluh
badanya panas, lemes, tak ada nafsu makan, lidah terasa pahit, konstipasi, perut nyeri.
Hasil pemeriksaan lidah pasien kotor, tepi lidah merah, TD 100/60 mmHg,
Nadi 100 kali permenit, pernapasan 20 kali permenit, Suhu axilla 390 C.
Apakah tindakan keperawatan yang akan saudara lakukan pada pasien tersebut ?
Pemberian kompres hangat
Anjurkan Bed rest total
Pemberian diit lunak
Pemasangan infus
Huknah rendah
Seorang laki-laki berusia 30 th dirawat di RS dengan diagnose medis hepatitis viral
akut. Hasil pengkajian pasien mengeluh pusing, mual, muntah, tampak lemah, sklera
tampak ikterik, suhu 395 0 C.
Apakah diet yang tepat untuk pasien di di atas ?
Diet lembek rendah lemak
Diet lembek rendah garam
Diet lembek rendah kalori
Diet lembek tinggi kalori
Diet biasa tinggi protein
Seorang perempuan 17 tahun status belum menikah ditunggui oleh kedua orang tuanya
dan pacarnya. Pasien dilakukan apendiktomi dengan general anestesi. Pada saat di

b.
d.

a.
b.
c.
d.
e.

lakukan palpasi abdomen ditemukan pembesaran uterus, setelah dilakukan test urine
positif hamil.
Apakah yang harus dilakukan perawat terkait dengan informasi kehamilanya tersebut ?
Mengimformasikan segera kepada pacarnya saja
Mengimformasikan kepada orang tua & pacarnya
Mengimformasikan kepada pasien setelah pasien sadar
Mengimformasikan segera kepada kedua orang tuanya saja
Tidak memberikan informasi kehamilan pasien karena menjaga privasi pasien
Seorang pasien perempuan berusia 16 tahun diantar oleh orang tuanya masuk IGD
dengan riwayat deman sejak 3 hari yang lalu. Saat ini pasien mengeluh mual, mutah
dan nyeri ulu hati. Hasil pemeriksaan ditemukan data: Tekanan darah 100/70 mmHg,
Nadi 90 kali permenit, pernapasan 20 kali permenit, suhu 390 C, Haemoglobin plasma
13 gr/dL, trombosit 100.000mm3, Hematokrit 36 vol %
Apakah masalah keperawatan utama pada pasien di atas ?
Nyeri akut
Hipertermia
Gangguan rasa nyaman mual
Gangguan nutrisi kurang dari kebutuhan tubuh
Resiko gangguan keseimbangan cairan elektrolit