Asuhan Keperawatan Gawat Darurat

shock

Setyo Martono

Program Studi SI Keperawatan

Fakultas Ilmu Keperawatan dan Kesehatan
Universitas Muhammadiyah Semarang
Tahun 2018
Introduction
 Life-threatening condition
 Be aware of physiologic effects of shock
 Be able todetect
 Report the development or worsening of this very
serious condition

Core Skills Treat for Shock

Shock Syndrome
 Kondisi penghantaran oksigen dan nutrisi tidak mencukupi metabolik
sel
 Syok merupakan suatu sindrom dan bukan suatu penyakit tersendiri
 Syok adl penurunan pengiriman darah teroksigenasi ke jaringan
(hipoperfusi)
RUMUS :
Pengiriman Oksigen Ke Jaringan Tiap Menit (DO2) =
Jumlah oksigen dalam darah x Curah Jantung (CO)
Curah Jantung : CO = SV X HR
SV: dipengaruhi oleh PRELOAD, AFTERLOAD dan KONTRAKTILITAS
Hypoperfusion…So What?
Inadequate
Cellular
Oxygenation

Inadequate
Anaerobic LacticAcid
Energy
Metabolism Production
Production

Metabolic Metabolic
Cell Death!
Failure Acidosis
Compensatory Mechanisms
Stimulated by baroreceptors
• Increased heart rate
• Increased contractility
• Vasoconstriction
• Increased Preload
Cardiovascular Changes in Shock
Type Preload Afterload Contractility
Cardiogenic   
Hypovolemic   No change
Distributive   
Septic
early   
late   
Classification of Shock
• Shock Terkompensasi
– Perfusi kejantung dan otak mencukupi tetapi
perfusi ke jaringan perifer tidak mencukupi
– TD normal, takikardia, nadi lemah, kulit dingin
dan pucat, diaforesis, dapat diserta mual muntah

• Shock Hipotensif
– Mekanisme kompensasi gagal
– TD turun, hipoksi jaringan, perubahan tingkat
kesadaran dan tampak gejala disfungsi oran multiple
Other Classification
 Hypovolemic Shock
 Non-hemorrhagic Shock (Shock Distributif)
 Septic Shock

 Neurogenic Shock

 Anaphylactic Shock/Vasogenic Shock

 Cardiogenic Shock
 Obstruktif Shock
 Tamponade Perikardium
Core Skills
 Tension Pneumotoraks
Treat for Shock 9
Hypovolemic Shock
 Paling sering disebabkan karena perdarahan
 Terjadi penurunan volume cairan
 Tidak dapat mempertahankan sirkulasi yg adekuat
 Caused by:
 Vomiting and diarrhea
 Hemorrhage
 Luka bakar yg luas
 Dehidrasi berat

Core Skills Treat for Shock 10

Gambaran Klinis
• Takhipnea
•Takikardia
•Kulit dingin , pucat, sianotik, diafoersris terutama
ekstremitas
•Perubahan tingkat keasadaran
•Oliguria
Treatment for Hypovolemic Shock
Goals : untuk pemenuhan kembali volume
intravaskuler
 Maintain airway
 Control bleeding
 Baseline vital signs
 Level of consciousness

Core Skills Treat for Shock 26

Treatment for Hypovolemic Shock
 Raise the legs position (tinggikan tungkai)
 Jaga temperature normal
 Cegah hypothermia
 Therapy cairan
 Identifikasi sumber perdarahan
 Perkirakan volume darah yang hilang
 Resusitasi cairan (kristaloid/koloid)
 Pertimbangkan transfusi darah
 Drug therapy
 Observasi setiap 10-15minutes
27
Non-Hemorrhagic Shock
(Shock distributif)
 Septic Shock
 Neurogenic Shock
 Anaphylactic Shock/Vasogenic Shock

Core Skills Treat for Shock 15

Cardiogenic Shock
 Disebabkan disfungsi myocardium
 Terjadi penurunan cardiac output :
 Penurunan sirkulasi suplay darah (preload)
 Penurunan oxygen delivery

Core Skills Treat for Shock 16

Cardiogenic Shock
Assess for:
 Blunt trauma to thechest
 Cardiac tamponade
 Cardiac dysrhythmias
 Myocardial infarction
 Cardiac contusion
 Tachycardia
 Distensi JVP
 TD normal/hypotension
 Dyspnea
 Edema perifer
Core Skills Treat for Shock 17
Treatment for Cardiogenic Shock

 Berikan Oksigenasi
 Lakukan pemeriksaan diagnostik : Lab, EKG, X-Ray dan Echo
 Resusitasi cairan dengan hati2
 Jika normotensi : diuretik dan vasodilator diindikasikan
 Kurangi kebutuhan metabolik

Core Skills Treat for Shock 18

Septic Shock
o Bacterial infection menyebabkan infeksi sistemik
dan menimbulkan respon fisiologis (mediator
sitokin)
 Vasodilation in wound area
 General vasodilation
o Predisposisi sepsis :
 Diabetes
 Cirrhosis
 Infeksi Post partum
 Infeksi Post aborsi

Core Skills Treat for Shock 16

Gambaran klinis Septic Shock
o Terjadi 2 - 5 hari post injury
o Tanda gejala shock hangat : Penurunan SVR
akibat vasodilatasi, hipotensi,perfusi meningkat,
ekstremitas hangat, pengisian kapiler cepat
o Tanda gejala shock dingin : Peningkatan SVR,
hipotensi, tekanan nadi menurun, ekstremitas
dingin,pengisian kapiler lambat
o Perubahan status mental
o Demam akibat leukositosis

Core Skills Treat for Shock 20

Treatment for Septic Shock
 Lakukan primary survey : ABCD
 Berikan oxygenasi
 Pantau vital signs
 Dapatkan akses IV/IO
 Jaga normalitas temperature tubuh
 Cek lab : Darah rutin, AGD dan
kultur darah

Core Skills Treat for Shock 21

Neurogenic Shock
o Merupakan hilangnya inervasi sistem saraf
simpatik pada otot polos vaskuler secara tiba2 yg
menyebabkan Vasodilatasi dan hipotensi
o Caused by:
 Spinal cord injury
 Certain drugs : antikolenergis (Buscopan, sistabon)
 Brain stem, spinal or torso trauma
o Signs and Symptoms:
 Hypotensi
 Denyut jantung normal atau bradikardia
 TD rendah
Core Skills Treat for Shock 22
Treatment for Neurogenic Shock

 Posisikan supine atau trendelenberg

 Jaga kepatenan airway
 Berikan oxygen
 Baseline vital signs
 Level of consciousness
 Kontrol suhu lingkungan
 Berikan vasopresor : Noreepinephrine

Core Skills Treat for Shock 23

Anaphylactic Shock/Vasogenic Shock
o Terjadi reaksi alergi multisistem akut akibat reaksi
berat alergen
o Onset 30 minutes setelah terpapar
o Terjadi vasodilatasi arteri dan vena
o Penurunan curah jantung
o Reaksi allergic :
 Drugs
 Toxins
 Insect stings
 Foods
 Plants
Core Skills Treat for Shock 24
Symptoms
• Gelisah, cemas, agitasi
• Difficulty breathing : Wheezing, stridor
• Takikardia
• Hipotensi
• Cyanosis
• Urtikaria
• Angioedema
• Mual - muntah
• Coma

Core Skills Treat for Shock 25

Treatment for Anaphylactic Shock
 Secure airway
 Hentikan paparan agen penyebab
 First-line therapies (tahap akute) :
 Epinephrine (0,01 mg/kg) dapat diulang 10 -15 mnt bila perlu
 IV fluids : kristaloid
 Oxygenasi
 Second-line therapies :
 Antihistamines (diphenhydramine)
 Corticosteroids

Core Skills Treat for Shock 26

Obstruktif Shock
 CO terhambat karena obstruksi aliran darah
 Terjadi hipotensi
 Disebabkan :
 Tamponade perikardium ( dilakukan drainase perikardium)
 Tension Pneumotoraks ( dilakukan chest decompresion, WSD)
Assesment
Primary survey
A = Airway (snoring, gargling, wheezing, obstruksi jalan nafas)
B = Breathing (takipnea, retraksi, sianosis, gasping, apnea)
C = Circulation (TD, JVP, takikardia, reguler/irreguler, intake
output cairan)
D = Disability (ansietas, gelisah/konfusio, tidak sadar)
E = Ekposure
Secondary survey
F = TTV : TD, RR, P, Sat O2, suhu
G = Kaji nyeri dg VAS, Wong Baker, CPOT
H = A : Allergies
M : Medications
P : Previous medical/surgical history.
L : Last meal (Time)
E : Events /Environment surrounding the injury
I = log rool (DCAP BTLS)
Head to toe assesment
Pemeriksaan penunjang : lab (DR, RFT, enzym jantung, urinalisa), ECG,
funduscopy, radiologi (MSCT, USG, X thorak)
Masalah keperawatan

1. Gangguan keseimbangan cairan, lebih/kurang

2. Penurunan curah jantung
3. Ketidakefektifan perfusi jaringan ( cerebral, ginjal)
4. Penurunan perfusi jaringan miokard
5. ……………………………dst