48678789 asuhan keperawatan trauma dada

7/29/2019 48678789 Asuhan Keperawatan Trauma Dada

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Asuhan Keperawatan Klien dengan Trauma dadaTuti Herawati, SKp, MN


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Introduction Struktur Organ: Jantung, pembuluh darah besar, esofagus, trakeobronkial dan paru-paru 25% of kematian akibat KLL disebabkan karena trauma dada Trauma abdomen umumnya disertai dengan trauma dada Penyebab: trauma tumpul dan trauma tajam Fokus

pencegahan Sistem yang memperbaiki keselamatan penumpang seperti airbags, safety belt


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Anatomi & Fisiologi Thorax Tulang dinding thorax 12 pasang tulang-tulang iga yang berbentuk C Ribs 1-7: Join at sternum with cartilage end-points Ribs 8-10: Join sternum with

combined cartilage at 7 th rib Ribs 11-12: No anterior attachment

Sternum Manubrium Joins to clavicle and 1st rib Jugular Notch

Body Sternal angle (Angle of Louis) Junction of the manubrium with the sternal body Attachment of 2nd rib

Xiphoid process Distal portion of sternum


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PENYEBAB TRAUMA DADA Trauma TajamPanah, pisau, handguns, Shotguns, tergantung jarak dengan senjata dan kaliber.Type I: >7 meters: injuri jaringan lunak Type II: 3-7 meters : penetrasi ke fascia dan organ internal Type III:


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Penyebab Trauma dadaTrauma Tumpul


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Injuri yang menyertai trauma pada dada Closed pneumothorax Open pneumothorax (including sucking chest wound) Tension pneumothorax Pneumomediastinum Hemothorax Hemopneumothorax Laceration of vascularstructures Tracheobronchial tree lacerations Esophageal lacerations Penetratingcardiac injuries Pericardial tamponade Spinal cord injuries Diaphragm trauma Intra-abdominal penetration with associated organ injury


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Dinding dada Contusion Umumnya disebabkan trauma tumpul Signs & Symptoms Erythema Ecchymosis DYSPNEA Nyeri saat bernafas Suara nafas yang menurun Limi

breath sounds HYPOVENTILAsi (nyeri saat bernafas) Crepitus Gerakan dinding dadaparadox


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Dinding dada Fraktur Iga >50% trauma dada disebabkan oleh trauma tumpul Compressional forces flex and fracture ribs at weakest points Iga 1-3 diperlukan kekauatan yang besar bila terjadi fraktur, dapat menuebabkan injuri paru Iga 4-9 tempat yang paling umum terjadi

farktur Iga 9-12 jarang terjadi fraktur Transmisikan energy trauma ke organ internal Bila fraktur, curigai adanya injuri

hepar dan limpa

Hypoventilasi umum terjadi karena nyeri


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Dinding dada Sternal Fracture & Dislocation Associated with severe blunt anterior trauma Typical MOI Direct Blow (i.e. Steering wheel)

Incidence: 5-8% Mortality: 25-45% Myocardial contusion Pericardial tamponade Cardiac rupture Pulmonary contusion

Dislocation uncommon but same MOI as fracture Tracheal depression if posterior


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Dinding dada Flail Chest Segment of the chest that becomes free to move with the pressure changes of respiration Three or more adjacent rib fracture in two or more places Serious chestwall injury with underlying pulmonary injury Reduces volume of respiration Adds to increased mortality

Paradoxical flail segment movement Positive pressure ventilation can restore tidal volume


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Paradoxical chest wall movement


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The point of insertion in the chest most commonly occurs on the side (lateral thorax), at a line drawn from the armpit (anterior axillary line) to the side (lateral) of the nipple in males, or to the side (about 2 in [5 cm]) above the sternoxiphoid junction (lower junction of the sternum, or chest bone) in females.


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Injury Paru-Paru Simple Pneumothorax Closed Pneumothorax Progresses into Tension Pneumothorax

Occurs when lung tissue is disrupted and air leaks into the pleural space

Progressive Pathology Air accumulates in pleural space Lung collapses Alveoli collapse (atelectasis) Reduced oxygen and carbon dioxide exchange Increased ventilation but no alveolar perfusion Reduced respiratory efficiency results in HYPOXIA

Ventilation/Perfusion Mismatch


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Injury Paru-Paru Open Pneumothorax Free passage of air between atmosphere and pleural space Air replaces lung tissue Mediastinum shifts to uninjured side Air will be drawn through wound if woundis 2/3 diameter of the trachea or larger Signs & Symptoms Penetrating chest trauma Sucking chest wound Frothy blood at wound site Severe Dyspnea Hypovolemia


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Injuri Paru-paru Tension Pneumothorax Buildup of air under pressure in the thorax. Excessive pressure reduces effectiveness of respiration Air is unable to escape from inside the pleural space Progression of Simple or Open Pneumothorax


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Pulmonary InjuriesTension Pneumothorax Signs & Symptoms Dyspnea Tachypnea at first Progressive ventilation/perfusion mismatch Atelectasis on uninjured side Hypoxemia Hyperinflation of injured side of chest Hyperresonance of injured side of chest Diminished then absent breath sounds on injured side Cyanosis Diaphoresis JVD Hypotension Hypovolemia Tracheal Shifting LATE SIGN


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Injuri Paru-Paru Hemothorax Accumulation of blood in the pleural space Serious hemorrhage may accumulate 1,500 mL of blood Mortality rate of 75% Each side of thorax may hold up to 3,000 mL

Blood loss in thorax causes a decrease in tidal volume Ventilation/Perfusion Mismatch & Shock

Typically accompanies pneumothorax Hemopneumothorax


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Hemothorax sign & symptoms Blunt or penetrating chest trauma Shock Dyspnea Tachycardia Tachypnea Diaphoresis Hypotension

Dull to percussion over injured side


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Pulmonary Injury Pulmonary Contusion Soft tissue contusion of the lung 30-75% of patients with significant blunt chest trauma Frequently associated with rib fracture Typical MOI Deceleration Chest impact on steering wheel

Bullet Cavitation High velocity ammunition

Microhemorrhage may account for 1- 1 L of blood loss in alveolar tissue Progressive deterioration of ventilatory status

Hemoptysis typically present


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Cardiovascular injury Myocardial Contusion Occurs in 76% of patients with severe blunt chest trauma Right Atrium and Ventricle is commonly injured Injury may reduce strength of cardiac contractions Reduced cardiac output

Electrical Disturbances due to irritability of damaged myocardial cells Progressive Problems Hematoma Hemopericard Myocardial necrosis Dysrhythmias CHF & or Cardiogenic shock


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Myocardial contusion sign & symptom Bruising of chest wall Tachycardia and/or irregular rhythm Retrosternal pain similar to MI Associated injuries Rib/Sternal fractures

Chest pain unrelieved by oxygen May be relieved with rest THIS IS TRAUMA-RELATED PAIN Similar signs and symptoms of medical chest pain


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Cardiovascular injury Pericardial Tamponade Restriction to cardiac filling caused by blood or other fluid within the pericardium Occurs in


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Pericardial Tamponade Signs & Symptoms

Dyspnea Possible cyanosis Becks Triad JVD Distant heart tones Hypotension or narrowing pulse pressure

Weak, thready pulse Shock

Kussmauls sign Decrease or absence of JVD during inspiration Pulsus Paradoxus Drop in SBP >10 during inspiration Due to increase in CO2 during inspiration Electrical Alterans P, QRS, & T amplitude changes in every other cardiac cycle PEA


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Cardiovascular injury Traumatic Aneurysm or Aortic Rupture Aorta most commonly injured in severe blunt or penetrating trauma 85-95% mortality

Typically patients will survive the initial injury insult 30% mortality in 6 hrs 50% mortality in 24 hrs 70% mortality in 1 week

Injury may be confined to areas of aorta attachment Signs & Symptoms Rapid and deterioration of vitals Pulse deficit between right and left upper orlower extremities


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Assessment of the Thoracic Trauma Patient Scene Size-up Initial Assessment Rapid Trauma Assessment Observe JVD, SQ Emphysema, Expansion of chest Palpate Auscultate Percuss Blunt Trauma Assessment Penetrating Trauma Assessment

Ongoing Assessment


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General Management of the Chest Injury Patient Ensure ABCs High flow O2 via NRB Intubate if indicated Consider overdrive ventilation If tidal volume less than 6,000 mL BVM at a rate of 12-16 May be beneficial for chest contusion and rib fractures Promotes oxygen perfusion of alveoli and prevents atelectasis

Anticipate Myocardial Compromise Shock Management Fluid Bolus: 20 mL/kg AUSCULTATE! AUSCULATE! AUSCULATE!


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Management of the Chest Injury Patient Rib Fractures Consider analgesics for pain and to improve chest excursion Morphine Sulfate

CONTRAINDICATION Nitrous Oxide May migrate into pleural or mediastinal space and worsen condition


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Management of the Chest Injury Patient Sternoclavicular Dislocation Supportive O2 therapy Evaluate for concomitant injury Flail Chest Place patient on side of injury ONLY if spinal injury is NOT suspected

Expose injury site Dress with bulky bandage against flail segment Stabilizes fracture site

High flow O2 Consider PPV or ET if decreasing respiratory status

DO NOT USE SANDBAGS TO STABILIZE FX


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Trauma.org


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Management of the Chest Injury Patient Open Pneumothorax High flow O2 Cover site with sterile occlusive dressing taped on three sides Progressive airway management if indicated


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Management of the Chest Injury Patient Tension Pneumothorax Confirmation Auscultaton & Percussion

Pleural Decompression 2nd intercostal space in mid-clavicular line TOP OF RIB

Consider multiple decompression sites if patient remains symptomatic Large overthe needle catheter: 14ga


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Management of the Chest Injury Patient Hemothorax High flow O2 2 large bore IVs Maintain SBP of 90-100 EVALUATE BREATH SOUNDS for fluid overload

Myocardial Contusion Monitor ECG Alert for dysrhythmias

IV if antidysrhythmics are needed


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Management of the Chest Injury Patient Pericardial Tamponade High flow O2 IV therapy Consider pericardiocentesis; rapidly deteriorating patient

Aortic Aneurysm AVOID jarring or rough handling Initiate IV therapy enroute Mild hypotension may be protective Rapid fluid bolus if aneurysm ruptures

Keep patient calm


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Diagnosa keperawatan1. Ketidakefektifan pola pernapasan berhubungan dengan ekpansi paru yang tidak maksimal karena akumulasi udara/cairan. 2. Inefektif bersihan jalan napas berhubungan dengan peningkatan sekresi sekret dan penurunan batuk sekunder akibat nyeri

dan keletihan.

3. Perubahan kenyamanan : Nyeri akut berhubungan dengan trauma jaringan dan reflek spasme otot sekunder. 4. Kerusakan integritas kulit berhubungan dengan trauma

mekanik terpasang bullow drainage. 5. Hambatan mobilitas fisik berhubungan dengan ketidakcukupan kekuatan dan ketahanan untuk ambulasi dengan alat eksternal. 6. Risiko terhadap infeksi berhubungan dengan tempat masuknya organisme sekunderterhadap trauma.


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Ketidakefektifan pola pernapasan berhubungan dengan ekspansi paru yang tidak maksimal karena trauma.

Tujuan : Pola pernapasan efektive. Kriteria hasil : o Memperlihatkan frekuensi pernapasan yang efektive. o Mengalami perbaikan pertukaran gas-gas pada paru. o Adaptive mengatasi faktor-faktor penyebab. Intervensi : Berikan posisi yang nyaman, biasanya dnegan peninggian kepala tempat tidur. Balik ke sisi yang sakit. Dorong klien untuk duduk sebanyak mungkin. Observasi fungsi pernapasan, catat frekuensi pernapasan, dispnea atau perubahan tanda-tanda vital. Jelaskan pada klien bahwa tindakan tersebut dilakukan untuk menjamin keamanan


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Intervensi

Jelaskan pada klien tentang etiologi/faktor pencetus adanya sesak atau kolaps paru-paru. Pertahankan perilaku tenang, bantu pasien untuk kontrol diri dnegan menggunakan pernapasan lebih lambat dan dalam. Perhatikan alat chest drainase berfungsi baik, cek setiap 1 2 jam Periksa pengontrol penghisap untuk jumlah hisapanyang benar. Periksa batas cairan pada botol penghisap, pertahankan pada batas yang ditentukan. Observasi gelembung udara botol penampung. Posisikan sistem drainage slang untuk fungsi optimal, yakinkan slang tidak terlipat, atau menggantungdi bawah saluran masuknya ke tempat drainage. Alirkan akumulasi drainase bila perlu. Catat karakter/jumlah drainage selang dada. Kolaborasi dengan tim kesehatan

lain Pemberian analgetika. Konsul photo toraks.


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Inefektif bersihan jalan napas berhubungan dengan peningkatan sekresi sekret danpenurunan batuk sekunder akibat nyeri dan keletihan. Tujuan : Jalan napas lanca

r/normal Kriteria hasil : Menunjukkan batuk yang efektif. Tidak ada lagi penumpukan sekret di sal. pernapasan. Klien nyaman. Intervensi : Jelaskan klien tentang

kegunaan batuk yang efektif dan mengapa terdapat penumpukan sekret di saluran pernapasan. Ajarkan latihan pernapasan dan batuk efektif

Auskultasi paru sebelum dan sesudah klien batuk. Ajarkan mempertahankan hidrasiyang adekuat; meningkatkan masukan cairan 1000 sampai 1500 cc/hari bila tidak kontraindikasi. Dorong atau berikan perawatan mulut yang baik setelah batuk.Lakukan penghisapan lendir jika diperlukan

Kolaborasi dengan tim kesehatan lain : Pemberian expectoran, pemberian analgesik,


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48678789 asuhan keperawatan trauma dada

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