POKOK BAHASAN

 Triage
TRIAGE DAN ASUHAN  Proses keperawatan gawat darurat
KEPERAWATAN GAWAT
DARURAT
Emil Huriani, MN

SISTIMATIKA DALAM
PRINSIP UMUM ASKEP GADAR
PENANGANAN GAWAT DARURAT
 Cepat dan tepat
 Pelayanan utama: penyelamatan hidup, stabilisasi Triase
dan pencegahan kecacatan
Survei Primer + Resusitasi
 Monitoring kondisi pasien setiap perubahan
kondisi
Survei Sekunder
 Jaga keamanan diri perawat dan pasien
 Tetap menjaga aspek etik dan legal keperawatan Stabilisasi

Rujukan / Terapi Definitif

TRIASE DI UGD TRIAGE: FIVE-TIER SYSTEM

The ENA (ENA, 2011b)

 Level I: Resuscitation— This level includes patients who need
immediate nursing and medical attention, such as those with
cardiopulmonary arrest, major trauma, severe respiratory
distress, and seizures.
 Level II: Emergent— These patients need immediate nursing
assessment and rapid treatment. Patients who may be assessed
as level II include those with head injuries, chest pain, stroke,
asthma, and sexual assault injuries.
 Level III: Urgent— These patients need quick attention but can
wait as long as 30 minutes for an assessment and treatment.
Such patients might report to the ED with signs of infection,
mild respiratory distress, or moderate pain.

1
 TRIASE DI UGD
PRIORITAS KEGAWATAN
MERAH. (waktu respon 0 – 10 menit)
 Level IV: Less urgent— Patients in this triage category can wait
up to 1 hour for an assessment and treatment; they may include
those with an earache, chronic back pain, upper respiratory  Masalah A-B-C  Nyeri dada
symptoms, and a mild headache.
 Kesulitan Bernafas  Cedera multiple
 Level V: Nonurgent— These patients can wait up to 2 hours
(possibly longer) for an assessment and treatment; those with  Cedera Kepala berat  Trauma dada/abdomen
sore throat, menstrual cramps, and other minor symptoms are
 Cedera tulang belakang  Kelainan persalinan
typically assigned to level V.
 Syok  Pendarahan tidak terkontrol
 Kejang

PRIORITAS KEGAWATAN PRIORITAS KEGAWATAN

KUNING. (waktu respon 30 menit) HIJAU. (waktu respon 60 menit)

Fraktur tertutup, dislokasi, luka minor, batuk

 Nyeri karena gangguan paru
 Luka bakar
 Penurunan kesadaran (GCS > 8)
 Diare dengan dehidrasi sedang HITAM. DOA (Death on Arrival)
 Muntah terus menerus Waktu respon: 120 menit
 Panas tinggi

PREDIKTOR FISIOLOGIS PADA

KETEPATAN PELAYANAN
AUSTRALASIAN TRIAGE SYSTEM

2
 LATIHAN BERPIKIR KRITIS
Menggunakan referensi yang tersedia, jelaskan level triage
dan tindakan keperawatan pada kasus dibawah ini:

 Asma
 Breathing problem
 Extremity injury
 Head injuri
 Pregnancy, vaginal
bleeding
 Seizure
 Chest pain
 Diabetic problem
 Heart rate rapid

PENGKAJIAN KEPERAWATAN GAWAT PENGKAJIAN KEPERAWATAN

DARURAT PADA NON TRAUMA GAWAT DARURAT PADA TRAUMA
Pengkajian Primer
A : Airway + Cervical Control
 A : Airway
B : Breathing + Ventilation
 B : Breathing
 C : Circulation C : Circulation + Hemorrhagic Control
 D : Disability D : Disability
 E : EKG E : Exposure + Hypothermia Prevention

A. AIRWAY B. BREATHING

 Menilai airway  Nilai Breathing

 Sadar: masih dapat berbicara, tanpa suara  Frekuensi pernafasan
tambahan  Sesak
 Tidak sadar: Look, listen, feel  Pucat, sianosis
 Ada kelainan  atasi  Oksigenasi
 Heimlich maneuver  Berikan oksigen
 Finger swab  Berikan bantuan nafas
 Head tilt chin lift, Jaw truss  Ventilasi
 Oropharingeal airway, nasopharyngeal airway

3
C. CIRCULATION D. DISABILITY

 Nilai sirkulasi  Tingkat kesadaran

 Raba denyut nadi  A = Alert
 Atasi permasalahan  V = Respon to voice
 Kompresi jantung luar  P = Respon to pain
 Kontrol pendarahan  U = Unrespinsive
 Perbaikan volume  Pupil dan tanda lateralisasi lain
 Ukuran dan reaksi pupil thd cahaya

E. EXPOSURE
Buka pakaian penderita
Periksa adanya luka, jejas, krepitasi
dan nyeri, dari kepala sampai ke kaki,
dimulai dengan bagian depan, dan
dilanjutkan dengan bagian belakang
Selimuti penderita
PRINSIP MANAJEMEN
KEGAWATDARURATAN PADA TRAUMA
LANJUT
 F = Folley Catheter
(kontra indikasi: Ruptur uretra)
Tanda:
Keluar darah dr orifisium uretra eksterna
Hematoma di skrotum/supra simphisis
Rectal touse: prostat melayang
 G = Gastric Tube
 H = Heart Monitor and Pulse Oksimetri

PENGKAJIAN SEKUNDER DIAGNOSA KEPERAWATAN

 Riwayat penyakit
 SAMPLE
 Sign and symptoms
 Allergy
 Medication
 Past medical history
 Last meal
 Event leading
 PQRST untuk mnegkaji nyeri
 Pengkajian head to toe
 Pemeriksaan penunjang (lab, roentgen, dll)
 Psikososial

4
EVALUASI DOKUMENTASI

REFERENSI

 Rossman, VGA. (nd). Emergency Nursing: 5-Tier Triage Protocol.

Philadelphia: Lippincott Williams & Wilkins
 Emergency Nursing Association. (2017). Emergency Nursing Core
Curriculum (7 Eds). Saunders: Elsevier Inc
 Solheim, J. (2016). Emergency Nursing: The profession, the
pathway, the practice. Indianapolis, USA: Sigma Theta Tau
International. Honor Society of Nursing.