PENGKAJIAN

KEPERAWATAN GAWAT
DARURAT
EMERGENCY NURSING ASSESMENT

NS. I KADEK ARTAWAN, M. KEP

POKOK BAHASAN
• PENDAHULUAN

• TRACK DAN TRIGER SISTEM

• INITIAL ASSESMENT

• SECONDARY SURVEY

• HIRAID-FAMEWORK

• DOKUMENTASI

• KESIMPULAN
 PENDAHULUAN
As recently as 2005 , the National Confidential Enquiry into
Patient Outcome and Death (NCEPOD) report of care in 1154
acute medical patients in 179 English hospitals found:
• Initial assessment was unacceptable in 10% of case
• Initial treatment was delayed and inappropriate in 48% of
cases
• Care was less than good practice in 47% of patients, and
contributed to death in one - third of the cases.
 PENDAHULUAN
Most often, poor patient outcomes are linked to delayed
recognition and ineffective management of fundamental
aspects of care, such as:
• Ensuring a clear airway
• Optimising breathing and giving oxygen
• Treatment of circulatory failure.

(McQuillan et al, 1998 ; McGloin et al, 1999 )

 TRACK AND TRIGER SYSTEM
EARLY WARNING SYSTEM
 TRACK AND TRIGER SYSTEM
EARLY WARNING SYSTEM
INITIAL ASSESMENT
 INITIAL ASSESMENT
Airway
 Ada snoring gunakan
jaw thrust
 Gurgling lakukan
suction
 Stridor lakukan
pemeriksaan
obstruksi jln nafas
 INITIAL ASSESMENT
Breathing
 Tdk ada nafas berikan
ventilasi
 RR < 10x/mnt ventilasi
10-20x/mnt dan O2
 Tidal volume rendah
berikan ventilasi
 Normal atau cepat
berikan oksigen
 Sulit bernafas berikan O2
non rebreathing 15
lt/mnt
 INITIAL ASSESMENT
Circulation
 Tdk ada nadi CPR
 Bradikardi pertimbangkan
shock spinal dan cedera
kepala
 Takikardi pertimbangkan
shock dan lihat adanya kulit
pucat, teraba dingin dan
basah
 Sianosis berikan O2 100% &
pertimbangkan ventilasi
 Perdarahan besar berikan
tekanan
 INITIAL ASSESMENT
DISABILITY
 Respon - AVPU
 Kesadaran-penurunan
kesadaran ada masalh dalam
otak atau penurunan perfusi
otak
 GCS; jika abnorrmal lakukan
pemantuan secara berkala
pada pasien GCS
 Pupil
 Refleks cahaya
 INITIAL ASSESMENT
Exposure
 Deformitas lakukan
imobilisasi/pembidaian
 Laserasi berikan suuring dan
perawatan luka
 Penetrasi pada dada dan
abdomen berikan bebat
tekan tiga sisi
 Luka bakar pertahankan
kelembaban dan rawat luka
agar tidak nyeri
 SEKUNDER SURVEY
• Berisi alasan utama pasien
datang ke rumah sakit
KELUHAN UTAMA

• Kronologis dari
RIWAYAT/MEKANISME ceder/keluhan yang
CEDERA menyebebkan datang
kerumah sakit
 SEKUNDER SURVEY
SAMPLE
SIGN AND SYMPTOM

ALLERGY

MEDICATION

PAST MEDICAL HISTORY

LAST INTAKE

EVEN LEADING INJURY

 HIRAID FAMEWORK
Latar Belakang
Kebutuhan akan kerangka pengkajian
keperawatan gawat darurat

• Prevalence of adverse event

• Peningkatan perawat ED NOVICE
• Belum tersedia sistem universal atau
valid sebagai acuan dalam pengkajian
keperawatan gawat darurat.
HIRAID FAMEWORK
 HIRAID FAMEWORK
History
POIN kunci dalam menanyakan riwayat adalah:
• Pain HISTORY
• Associated symptoms
• Past medical history/past surgical history
• Medication
• Allergies
• Last menstrual period
• Significant events in past 24 h/mechanism of injury
• Current treatment for the presenting problem
• Social history
 HIRAID FAMEWORK
Potensial ‘‘REDFLAGS’’

 The first priority is to establish the severity of threat to life

or limb and hence the need for medical intervention.
 In determining the severity of the patient’s illness and the
need for immediate intervention, the emergency nurse relies
on a combination of clinical signs and historical factors.
 HIRAID FAMEWORK
‘‘ASSESMENT’’

 ABCDE-TEKNIK.
 Focused assessment, usually directed by presenting signs
and symptoms, or the mechanism of injury
 Diagnostik atau tes Laboratoirum
 HIRAID FAMEWORK
‘‘INVESTIGATON’’

• The availability of diagnostic and laboratory testing assists in identifing

a path to definitive care for patients admitted to the emergency
department.
• determining which diagnostic and laboratory tests might be required is
not a primary nursing responsibility
• the rational use of test ordering such as ‘STOP’ Sensible Test Ordering
Procedure18 should also be aconsideration in conjunction with the clinical
assessment.
 HIRAID FAMEWORK
‘‘NURSING INTERVENTION’’

• Nursing assessment process is interactive and nonlinear, many actions

may occur simultaneously.
• The reassessment of patients in response to nursing interventions, as
well as potential deterioration is core to the emergency nursing
assessment process, as is patient safety, verbal and written
communication.
 HIRAID FAMEWORK
‘‘The role of communication in the ENAF’’

• Communication in the emergency department can be chaotic,

unstructured, urgent and part of simultaneous multitasks and
synchronous workloads.
• Poor communication and communication overload has a direct
correlation with patient outcomes adverse events, transfer delays and
length of stay.
 DOKUMENTASI
Nursing documentation is an essential part of patient
care and is intended to:
• Reflect the care administered to the patient
• Provide a chronology of patient progress or response
to treatment
• Communicate clinically significant information to other
members of the health care team
• Provide justification for charges and billing
 DOKUMENTASI
Hospitals accredited by The Joint Commission are required to
provide certain information on the medical record. The medical
record should be :
• Clear and objective
• Realistic and factual
• Composed of one’s own observations
• Free of opinions, generalizations, and ambiguities
• Grammatically written, without spelling errors
• Devoid of unapproved abbreviations. The Joint Commission
issued a “Do Not Use” list of abbreviations
DOKUMENTASI
DOKUMENTASI
DOKUMENTASI
DOKUMENTASI
 DAFTAR PUSTAKA
Perry, AG. 2005. Buku Saku Keterampilan dan Prosedur Dasar. Jakarta: EGC
Hudak dan Gallo, 1996, Keperawatan Kritis: Pendekatan Holistik, EGC: Jakarta
Iyer, P. 2004. Dokumentasi Keperawatan: Suatu Pendekatan Proses
Keperawatan, Jakarta:EGC.
Jevon, Philip, 2007, Emergency Care and First Aid for Nurse: A Practical
Guide, Churchill Livingstone Elsevier: China
Newberry , L. dan Criddle L.M. (Eds.), 2005, Sheey’s Manual of Emergency
Care, 6th Ed, Elsevier Mosby: USA
Oman, K., 2007, Emergency Nursing Secret, 2nd Ed, Mosby Elsevier: USA
Ooi, S., Manning, P., 2004, Guide to The Essentials in: Emergency Medicine, Mc
Graw Hill Education: Singapore.
Price, S.A, 2000, Patofisiologi, EGC: Jakarta
 DAFTAR PUSTAKA
 Purwadianto, S.B, (2000), Kedaruratan Medik, Jakarta: Bina Rupa Aksara
 Toulson, S, 2003, Accident and Emergency Nursing, Whurr Publisher Ltd: UK
 Smeltzer, 2002, Keperawatan Medikal Bedah, Edisi 8. Jakarta: EGC.
• Woloshynowych M, Davis R, Brown R, Vincent C. Communication Patterns in a UK Emergency
Department. Annals of Emergency Medicine 2007;50(4):407—13.
• Hindle D, Braithwaite J, Iedema R, Travaglia J. Patient safety: a review of key international
enquiries. Sydney: University of
• New South Wales; 2005. 21. Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE.The
association between interdisciplinary collaboration and patient outcomes in a medical intensive
care unit. Heart Lung 1992;21:18—24.
• White AA, Wright SW, Blanco R, Lemonds B, Sisco J, Bledsoe S, et al. Cause-and-effect analysis of
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Emergency Medicine 2004;11(10):1035—41.
• Vincent CA, Wears R. Communication in the emergency department: separating the signal
from the noise. Medical Journal of Australia 2002;176:409—10.
• Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe ME. Communication loads on
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2002;176:415—8.
• Sprivulis PC, Da Silva J, Jacobs IG, Brazer ARL, Jelinek GA. The association
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