Konsep kegawatan dan asuhan

keperawatan pada klien gangguan

reproduksi Aspek kehamilan dan persalinan
dengan kegawatandaruratan

Disampaikan pada keperawatan gawat darurat 2 Prodi Keperawatan FK

Untan
By. Ns. Maria Fudji Hastuti, M.Kep
 INTRODUCTION

 HYPERTENSIVE DISORDERS

 HELLP SYNDROME
• SEVERE ASTHMA
 PERIPARTUM CARDIOMYOPATHY
• SEPTIC PELVIC
THROMBOPHLEBITIS
 THROMBOEMBOLIC DISEASE
• ADVANCED LIFE SUPPORT
IN PREGNANCY
PHYSIOLOGIC ALTERATION

1. Pulmonary

2. Cardiovascular

3. Gastrointestinal

4. Hematologic
 pulmonary

 Pada kehamilan terjadi perubahan pada paru paru dengan peningkatan TIDAL
VOLUME dan penurunan FRC ( Functional residual capacity)

 Tidal volume menurun sekitar 40%

 Penurunan FRC menyebabkan kecenderungan terjadinya atelektasis

 Kebutuhan O2 meningkat sekitar 30-40 ml/men

 Pa CO2 menurun sekitar 30 Torr, pH tidak berubah dgn kompensasi penurunan

serum bicarbonate
 cardiovascular


 Volume darah meningkat pada tiap trimester kehamilan

 Cardiac output meningkat 30-50% terutama pada trimester pertama yg berarti

peningkatan stroke volume dan heart rate

 Penurunan cardiac output 25-30% pada trimester ketiga saat berbaring

terlentang, karena adanya gangguan venous return.

 CVP normal,peningkatan Cardiac output dan tekanan darah menurun pd

trimester kedua , ds menyebabkan penurunan SVR (Systemic vascular
resistance)
 GASTROINTESTINAL

 Perubahan hormonal dan anatomi mempengaruhi perubahan traktus

digestivus

 Penurunan tekanan sfingter esophagus bag bawah, menyebabkan

peningkatan reflux gastoesophageal dan menyebabkan peningkatan
kemungkinan terjadinya aspirasi

 Memburuknya fungsi motorik lambung menyebabkan adanya mual dan

muntah
 HEMATOLOGI

 Peningkatan plasma 40-60% pd trimester ketiga diikuti peningkata sel darah

merah hanya 25%, sehingga terjadi anemia karena dilusi sehingga kadar
Hb lebih rendah, leukosit meningkat sampai 10.000 sel/ mm3 dan terjadi
penurunan sedikit thrombosit.

 Terjadi peningkatan semua faktor pembekuan kecuali faktor XI dan

XIII,fibrinogen meningkat (600 mg/dl) pd kehamilan aterm, disebut
abnormal bila < 400 mg/dl. Waktu perdarahan dan waktu pembekuan
dalam batas normal. Pada keadaan hiperkoagulasi akan meningkatnya
risiko thromboembolisme.
HYPERTENSIVE
DISORDERS
 preeclampsia

 Diagnosis didasarkan pada hipertensi yg ditandai dengan adanya proteinuria,

edema atau keduanya paa kehamilan diatas 20 minggu.

 Dikelompokkan dalam katagori berat bila;

 Pada saat istirahat sistolik > 160 mmHg atau diastolik > 110 mmHg
 Proteiuria > 5 g/24 jam, oliguria < 400 ml/24 jam
 Gangguan cerebaral dan visual
 Edema paru atau sianosis
 Nyeri epigastrik atau kuadran atas kanan
 Memburuknya fungsi hepar
 Thrombositopenia atau DIC
 ECLAMPSIA

 Adalah preeclamsia yang disertai dengan kejang, keadaan ini sering

diketemukan pada kehamilan dgn hipertensi

 Thrombositopenia, DIC, perdarahan intraserebral, gagal ginjal, HELLP

syndrome adalah keadaan yg sering menyertai preeclampsi atau
eclampsia

 Eclampsia sering muncul pada saat sebelum persalinan atau 2 hari pasca
persalinan
 PENANGANAN

 Pasien eclampsia dan preeclampsia berat memerlukan perawatan di RS

 Pemberian magnesium sulfat, monitoring keadaan ibu dan janin, rujuk kepada
dokter kebidanan

 Kemungkinan memerlukan rawat ICU atau dilakukan pengakhiran kehamilan

(pertimbangkan usia kehamilan)

 Hal penting yg harus dilakukan adalah pemberian oksigen dan meminimalkan

kemungkinan terjadinnya aspirasi
 PENANGANAN

 Pencegahan kejang; Mg SO4 (29% sol) im atau iv diberikan pd

preeclampsia. Terutama bila diastolik sdh> 100 mmHg atau terjadi visual
bluring, atau hyperefleksia.

 Pemberian Mg SO4 iv dengan loading dose 4 gr kemudian diikuti dgn infus

1-2 gr perhari. Pengecekan dalam 2-4 jam apakah terjadi peningkatan
refleks. Kadar diharapkan 4-7 meq/l dan monitor frek nafas, urine output
dan refleks. Kadar > 7 meq/l akan menyebabkan keracunan/ toksik yg
menganggu respirasi dan kardiovaskular. Bila urine output atau refleks
menurun maka kurangi kecepatan infus dan untuk mengatasi keracunan
Mg SO4 berikan Ca glukonas 1 gr i.v.
 penanganan

 Terapi thd tekanan darah adalah dgn menurunkan tek darah dan pasien
stabil tdk perlu menjadi normal .
 Pemberian anti hipertensi menyebabkan tekanan darah menurun dgn
cepat yg menyebabkan stree pd janin.dapat diberikan hydralazine atau
labetolol. Jarang diberikan beta bloker atau diuretika pemberian cakcium
channel bloker diberikan dengan pengawasan . ACE inhibitor
kontraindikasi, nitroprusid tdk diberikan
 penanganan

 Edema paru baik kardiak atau nonkardiak dpt terjadi pd preeclampsia berat.
Pemberian terapi O2 untuk mempertahankan PaO2 > 70 torr agar O2 utk janin
cukup. Bila diperlukan intubasi dan moda ventilasi dgn positif pressure.

 Intubasi dilakukan hati2 karena adanya risiko aspirasi, penigkatan hypoksemia,

edema pharynx. Ukuran ETT yg lebih kecil biasa dipilih (6 atau 6,5)

 Pada edema paru maka restriksi cairan harus dilakukan segera dan pemberian
diuretik.

 Oliguria sering pd eclampsi atau preeclampsia berat, maka perlu pemberian

cairan , bila tdk ada response maka monitoring hemodinamik secara invasive
diperlukan. Vasodilator mungkin diperlukan bila intravaskular cukup adekuat.
 HELLP
SYNDROME
 hellp

 H – hemolysis ( Apus darah tepi abnormal, total bilirubin >1,2 mg/dl, serum
lactat dehydrogenase/LDH > 600 U/l

 E - elevated , L – Liver enzymes : Aspartate aminotransferase (AST) > 70 U/l

atau LDH > 600U/l

 L-low, P –platelet count < 100.000/ mm3

 HELLP
 Syndroma ini manifestasi klinisnya tdk spesifik misalnya nyeri epigastrik, nyeri
quadrant atas kanan abdomen, malaise, nausea dan muntah

 Biasanya pd usia kehamilan 27-36 minggu, munkin juga postpartum.

Preeclampsi sering terjadi sebelum HELLP syndrome. Tetapi sepertga kasus
HELLP terjadi tanpa adanya hipertensi

 HELLP syndrome adalah bagian dari fibrinolysis atau hemolysisi pd

preeclampsia. Thrombocytopenia, DIC, perdarahan intracerebral , gagal
ginjal dan HELLP berbeda manifestasi , kadang@ spt Fatty liver shg pem
laboratorium penting
 PERIPARTUM
CARDIOMYOPATHY
Manifestasi klinik

 Biasanya 1 bulan setelah melahirkan, beberapa kasus didapatkan 6 bulan

setelah melahirkan

 Severe dyspne, progrssive orthopnea, paroxysmal nocturnal dyspnea

 Cardiomegaly (pd X ray), pulmanary hypertension, murmur, Jugular vein

distention, cyanosis, clubbing, arrhytmmia
MANAGEMENT

 X ray, EKG
 Echocardiogram
 Bedrest
 Restriksi sodium
 Diuretic atau vasodilator bl perlu
 Anticoagulant mungkin diperlukan
THROMBOEMBOLIC
DISEASE
MANIFESTASI KLINIK & MANAGEMENT

 Faktor signifikan penyebab kematian ibu.

 Pada periode post partum x dari angka kejadi ibu tdk hamil

 Pada pasien wanita African American yg hamil terdapat peningkatan

risiko pd kasus kelahiran melalui sectio cesaria atau pada opersi
pervaginam

 Suspek terjadinya emboli paru diperlukan pemberian heparin

SEVERE ASTHMA

 Diberikan O2 suplement

 Pada serangan athma dpt diberikan inhaled beta agonist dan

systemic steroids (pemberian parenteral cukup aman
Septic pelvic thrombophlebitis

 Dikarenakan bekuan di vena pelvis pada periode peripartum

.

 Pemberian heparin dan antibiotik dalam penanganan

Asuhan Keperawatan

Pengkajian
Diagnosa
Intervensi
Rehabilitasi
TRAUMA PADA KASUS KHUSUS
(Trauma pd anak dan pd kehamilan)
PRINSIP UMUM PENANGANAN TRAUMA

 EARLY MANAGEMENT
1. Primary assessment
2. Secondary assessment

 ONGOING EVALUATION
◦ Tertiary assessment
PEDIATRIC PATIENTS
PRIMARY ASSESSMENT

 The first goal is to establish adequate O2 delivery to vital organ

 Identification and treatment of immediate life threatening injuries

◦ A–B–C

 For pediatric patients.

◦ The same principles with adult
◦ Head injury , the most common serious injury in children
◦ Variation in body size and neurologic development require
special consideration for vital sign, equipment size, site of
vascular access, blood volume estimates, GCS assessment
AIRWAY – BREATHING ASSESSMENT

 After blunt trauma, airway control should proceed on the asumption that
an unstable cervical spine (C-spine) -> avoid any movement including
hyperextention

 The patency of the airway must be established and supplemental O2 must

be supplied as adequacy of ventilation is assessed. .
AIRWAY – BREATHING ASSESSMENT

 Active airway intervention to support oxygenation / ventilation. (important

before a cross table lateral radiograph of the C spine).

 If no time to obtain arterial blood gas measurements and bag mask

ventilation can be ineffectivein a combative, spontaneously breathing
trauma patients

 Nasotracheal intubation is a useful tachnique in the nonapneic patients

with suspected C spine injury. Standar orotracheal intubation performed
following unsucessful nasotracheal intubation or patient to be near
respiratory arrest
AIRWAY – BREATHING ASSESSMENT

 In line manual stabilization of the head and neck should be performed for
oral or nasal intubation>when the airway cannot be secured,
crycothyrotomy is indicated

 FOR PEDIATRICS
In infant and young children orotraheal intubation with in line stabilization is
the first of choice. Endotracheal tube size -> equal to diameter of the
child’s little finger. Needle & surgical cricothyrotomy are associated with
greater risk in small children.
CIRCULATION

 Haemmorrhage is the most likely cause of postinjury shock. Initial treatment

consists of crystaloid infusion via 2 large bore intavenous cannulas with control
of external hemorrhage by manual compression. Targets of volume therapy are
normalization of blood presure, reversal of tachycardia and maintenance of
adequate organ perfusion.

 FOR PEDIATRIC.
The initial crystaloid bolus in children with traumatic shock is 20 ml/kg. In childern
<6 yo a bone marrow resuscitation needle (intraosseus needle) is placed in the
anterior tibia if difficulty of i.v access. For difficult access in children > 6 yo,
femoral and suclavian vein cannulation can be accomplished .
 BLOOD VOLUME IN CHILDREN
Age group Weight (kg) Blood vol Total vol (ml)
(ml/kg)

Newborn 2,5- 4 90 290

Infant 4-12 75 600

2-4 yrs 10-20 75 1200

4-7 yrs 15-30 75 2000

7-12 yrs 20-50 75 2500

> 13 yrs > 40 70 3000-5000

 VITAL SIGN IN CHILDREN
Age group Heart rate Respiratory Systolic BP Diastolic BP
(beat/mnt) rate (mm Hg) (mm/Hg)
(breath.mn)
Newborn 100-180 30-60 50-70 25-50

Infant 80-180 30-40 85-100 50-60

2-4 yrs 70-140 20-30 87-105 53-66

4-7 yrs 60-110 20-30 95-105 53-66

7-13 yrs 60-100 16-20 97-112 57-71

> 13 yrs 50-90 12-16 112-128 66-80

BLEEDING IN TRAUMA

 In patients who arrive in shock. The most frequent sites are the chest,
abdomen or pelvis (Hemothorax, intra abdominal hemorrhage, pelvic
hemorrhage)

 FOR PEDIATRIC
DPL is used less frequently in the initial evaluation in children, but is useful in
the evaluation of ongoing hemodynamic instability
RESUSCITATION OF HEMORRHAGIC
SHOCK

 Management of hemorrhagic shock ; resuscitation use the crystalloid,

coloid, blood product and monitoring

 FOR PEDIATRIC
in children blood should be administered when crystaloid infusion is >
40ml/kg. the initial volume of PRC should be 10 ml/kg
SEVERE BRAIN INJURY

 The initial management of brain injury is directed at controlling intracranial

pressure (ICP)and maintaining O2 delivery and cerebral perfusion pressure
to prevent secondary injury

 FOR PEDIATRIC
children are less likely to have mass lessions amenable to treatment and
more often have ICP that is difficult to control> the overall prognosis,
however is better in children than adults.
SECONDARY ASSESSMENT IN TRAUMA

 Secondary assessment to identify and treat potentially life threatening

injuries. The assessment is crucial to allow proper triage to the operating
room or ICU.

 FOR PEDIATRIC
Consider child abuse when there are discrepancies between the history
and physical examination . If child abuse is suspected the work up should
include prothrombin time, partial thromboplastin time, platelet count, skull
radiograph and a skeletal survey. A fundoscopi exam to detect retina
hemorrage is helpful in confirming suspected abuse.
RADIOLOGIC EVALUATION

 In the evaluation of blunt mutiple system trauma, a lateral C spine to the

level of T1, supine chest radiograph and flat plate of the pelvis . The most
common error are inadequate visualization of C7-T1 and poor definition of
the occiput, C1 and C2 componen.

 FOR PEDIATRIC
40% of children < 7 y o have a pseudosubluxation of C2 on C3 which does
not represent a fracture. A supine chest X ray to identify pneumothorax
and hematothorax. Blood in chest cavity only as a hazy appearance on a
supine radiograph.s
CORE TEMPERATURE

 Hypotension and massive transfusion predipose to hypothermia

 FOR PEDIATRIC
because of their larger body surface area perunit body mass, children are
a higher risk than adult of becoming hypothermia
PREGNANT WOMAN
PHYSIOLOGIC ALTERATIONS

 Physiologic alteration unique in pregnancy

 Cardiovascular
 Pulmonary
 Gastrointestinal
 hematologic
CARDIOVASCULAR

 Blood volume imcreases in each trimester during pregnancy

 Cardiac output increases 30-50% during normal pregnancy. A significant

decreases 25-30% in third trimester when the patient is placed in the supine
position.

 CVP does not change during pregnancy

 Increases CO, decreases BP (the lowest in 2nd trimester) as a result of

diminished systemic vascular resistance (SVR)
PULMONARY

 Pulmonary changes in pregnancy include an increase in Tidal volume of

approximately 40% and decreases in functional residual capacity (FRC)

 The reduction in FRC predisposes the patient to atelectasis if critical illnes

develops.

 O2 requirement increase 30-50ml/min in pregnancy , increase minute

ventilation

 PaCO2 decrease but pH does not change secondary to a compensatory

decrease in serum Bicnat concentration
GASTROINTESTINAL

 Hormonal in anatomic changes in pregnancy affect the gastrointestinal

tract.

 A reduction in lowe esophageal spinchter pressure with increase in

gastroesophageal reflux contributies to an increased risk for aspiration.

 Alteration in gastric motor function may manifest as nausea and vomiting

HEMATOLOGIC

 The 40-60% increase in plasma volume that occurs by the 3rd trimester is
associated with an increase in red cell mass of only 25% at term.

 The dispropotionate increase in plasma volume result in dilutional anemia with a

Hb concentration of 11 g/dl at 24 weeks. The white blood count increase to
10.000 cells/mm2, with a slight decrease in platelet count.

 Concentrations of all clotting factors except F. XI and increase F. XVIII.

Fibrinogen as high as 600 mg/dl, if < 400 mg/dl abnormal.

 Although coagulation test and bleeding times do not change, the

compositional change result in hypercoagulable state with increased risk for
thromboembolism
TRAUMA IN PREGNANCY

 Treatment priorities for the pregnant patient with trauma are the same as
those for nonpregnant patients.

 The unique changes during clinical assessment,

◦ The height of uterus is roughfly at the symphysis pubis at 12 weeks, the umbilicus at
20 weeks, then the height increases by 1 cm/week thereafter up to 36-40 weeks
◦ Late in pregnancy there can be widened symphysis pubis and widened sacroilliac
joints
TRAUMA IN PREGNANCY

 The neurologic symptoms of eclampsia may mimic head injury

 The initial abdominal assessment of the pregnant patient is complicated

by the gravid uterus. Venocaval compression can contribute to
hypotension by restricting the return of blood to the heart. Usually the
patient placed in the left lateral decubitus position

 The spinal injury elevation of the right hip should be done manually to
displace the uterus to the left
TRAUMA IN PREGNANCY

 The pregnant patient can lose up to 35% of blood volume before

tachycardia, hypotension and other sign of hypovolemia.

 The fetus may actually be in a state of hypoperfusion while the mother’s

condition seems stable. An assessmentof the fetal heart rate is essential to
the initial survey, use fetoscope or doppler fetoscope. A conventional
stetoscope can be use auscultate the fetal heart rate in the 3rd trimester
(normal 120-130 beats/min). A minimum 4 hours of fetal monitoring is
necessary after trauma.
TRAUMA IN PREGNANCY

 Secondary assessment should evaluate uterine irritability (spasm of the

uterus), fetal heart rate, fetal movement, and pelvic examination.

 If there is blood from vagina a qualified experienced person should do a

speculum exam. It is contraindicated to do a vaginal manual exam with
the possibility of placenta previa.
TRAUMA IN PREGNANCY

 Definitive care of the pregnant trauma patient includes adequate

hemodynamic and respiratory resuscitation, stabilization of the mother,
continued fetal monitoring and radiographic studies as necessary, in
addition to obstetric, critical care and surgical consultation.
THANK YOU
Deteksi Dini Kegawatdaruratan
Neonatus dan Upaya
Merujuknya

Disampaikan pada keperawatan gawat darurat 2 Prodi Keperawatan

FK Untan
By. Ns. Maria Fudji Hastuti, M.Kep
55
3 Macam Kondisi Bayi Baru Lahir
(BBL)

 BBL risiko rendah (Perawatan level I)

 BBL risiko menengah (Perawatan level II)
 BBL risiko tinggi (Perawatan NICU)
 BBL Risiko Rendah
56

 -NCB-SMK
-NKB (gestasi > 36 mgg; dan atau BL > 2000 g)*
-BBLR > 2000 g*
-Bayi dengan asfiksia ringan*
 Riwayat kehamilan, persalinan, kelahiran dan
pasca persalinan normal
 Tanda vital normal
 Pemeriksaan fisis normal
* Klinis dinilai tak ada kelainan
57 BBL Risiko Menengah

 Bayi dengan infus

 Usia gestasi < 36 mgg. Bayi sehat setelah 24-48 jam dapat kembali ke ruang
rawat level I jika monitor dilakukan secara adekuat
 Perlu terapi O2
 Asfiksia intrapartum yang tidak terlalu berat
 Memiliki tanda-tanda hipoglikemia
 Ibu diabetes
58 …BBL risiko menengah

 Sesak napas tanpa bantuan ventilator

 Rhesus isoimmunisation
 Sakit ringan tanpa diagnosis yang jelas
 Tersangka sepsis, tetapi tidak berat
59 BBL Risiko Tinggi

 Berat lahir < 1200 g

 Sesak napas yang memerlukan bantuan ventilator
 Apnea rekuren berat
 Eritroblastosis berat
 Bayi sakit dan membutuhkan perawatan khusus
 Pneumotoraks yang memerlukan drainase
interkostal
60 Berbagai Masalah Kegawatdaruratan
Neonatus
 Suhu  hipotermi, hipertermi
 Pernapasan  apnea, sesak, hipoksia
 Sirkulasi  syok/renjatan
 Saluran cerna  kembung, muntah
 Traktus urinarius  anuri, poliuri
 Metabolisme  hipoglikemi, hipokalsemi
 Lain-lain  perdarahan, kejang, kuning
 Cara merujuk
61 Masalah Suhu

 Normal : 36,5 – 37,5o C

 Pengukuran di aksila selama 3’
 Hindari pengukuran di anus
 4 cara kehilangan panas : konduksi, evaporasi, konveksi, dan radiasi

Hipotermi adalah pembunuh utama

pada neonatus
 Mekanisme kehilangan panas
62
63 Upaya Menurunkan Risiko Hipotermi

 Suhu optimal untuk ruangan bersalin/OK dan ruang

perawatan
 Suhu ruangan bayi ideal 24 – 26o C
 Alas tidur dan handuk pembungkus hangat
 Inkubator transpor hangat
 Saat melakukan tindakan, pastikan bayi hangat
 Pintu inkubator jangan sering dibuka
 Bila sudah stabil  metode kanguru
64

Metode
Kanguru
65

Metode
Kanguru
66

Metode
Kanguru
67

Metode
Kanguru
68 Masalah Pernapasan

 Normal : RR 40 – 60 x/menit
 Bedakan “Periodic Breathing” dengan apnea
 Apnea : stop napas > 20 detik, atau kurang dari 20 detik, tapi disertai
bradikardi dan atau SpO2 menurun
 Evaluasi Respiratory Distress dengan
69
Skor Down
0 1 2
Frekuensi Napas < 60x/menit 60-80 x/menit >80x/menit

Retraksi Tidak ada Retraksi ringan Retraksi berat

retraksi
Sianosis Tidak sianosis Sianosis hilang Sianosis menetap
dengan O2 walaupun diberi
O2
Air Entry Udara masuk Penurunan Tidak ada udara
ringan udara masuk
masuk
Merintih Tidak merintih Dapat didengar Dapat didengar
dengan tanpa alat bantu
stetoskop
70
…evaluasi respiratory distress
dengan skor Down

 Skor < 4 : tidak ada gawat napas

 Skor 4 – 7 : gawat napas
 Skor > 7 : ancaman gagal napas (pemeriksaan gas darah harus
dilakukan)
71 Upaya Mengatasi Hipoksia

 Berikan O2 seoptimal mungkin

 O2 nasal 0,5 – 2 L/menit
 O2 head box 3 – 5 L/menit
 Kadang-kadang boleh dimix antara O2 head box 5 L/menit + O2 nasal
s/d 2 L/menit sambil dipersiapkan CPAP atau ventilator
72 Masalah Sirkulasi

 Normal HR 120 – 140 x/menit

 Periksa kualitas isi nadi, waktu pengisian kapiler (N < 2 detik)
 Tensi bayi harus diukur dengan manset yang sesuai (no. 1 – 2 – 3 – 4); yang
dilaporkan MAP
 Normal : bradikardi saat tidur
73 Upaya Mengatasi Renjatan

 Berikan cairan isotonus 10 ml/kg/x selama setengah jam dapat diulang 2x

 Tidak ada perubahan  inotropik
Dopamin/dobutamin 5 – 10 µg/kg/menit
 Caranya : 30 mg/kgBB inotropik, larutkan dalam Dx 10 % sampai 50 ml,
jalankan 1 ml/jam
74 Masalah Saluran Cerna

 Kembung, muntah, perdarahan  NEC

 Syarat pemberian minum:
 Tidak sakit berat
 Sirkulasi baik
 Residu yang dapat ditolerir: < 15 – 20 % dari total minum sebelumnya
 Mekonium harus keluar < 48 jam
75 Masalah Traktus Urinarius

 Urin harus keluar < 24 jam

 Normal 2 – 4 ml/kg/jam
 Oliguri/anuri : mungkin hipoalbuminemi/syok
 Bayi dengan Risiko Hipoglikemia
76

Berhubungan dengan faktor ibu :

 Pemberian infus glukosa intrapartum

 Pemberian obat :
 Terbutalin, Ritodrin, Propanolol
 Oral hypoglycaemic agents

 Diabetes yang tidak terkontrol

 Asfiksia perinatal (pH arteri umbilikus
<7,20)
77 …bayi dengan risiko hipoglikemia

Berhubungan dengan faktor neonatus :

Idiopatik atau adaptasi yang gagal

Asfiksia
Infeksi
Hipotermia
Polisitemia
Hidrops fetalis, eritroblastosis fetalis
78 …bayi dengan risiko hipoglikemia

 Prematur
 Gangguan perkembangan intrauterin
 Gangguan endokrin
 Inborn errors of metabolism
79 Hipoglikemia

 Normal Gula Darah Sewaktu (GDS) : > 40 – 45 mg/dl s/d 120 mg/dl
 Periksa GDS : Heel prick : kaki harus hangat, merah, usap pakai alkohol 70
%, dan tunggu sampai kering
 Glucose Infusion Rate (GIR) : 4 – 6 mg/kg/menit
Rumus ……% Dx X ……ml/jam
6 X BB
80
Hipoglikemia

 Awalnya cairan Dx 10 %  60 ml/kg/hari

 Bila hipoglikemia  Dx 10 % 2 – 4 ml/kg bolus
 Bila hipoglikemia menetap  insulin drip
81 Hipokalsemia

 Definisi:
 Kadar kalsium serum < 7 mg/dL (1,75 mmol/L)
 Prematur : < 7 mg/dL (1,75 mmol/L)
 Cukup bulan < 8 mg/dL (2,00 mmol/L)
 Kadar kalsium ion (lebih sensitif) 4,4 mg/dL (1,10 mmol/L)
82 …Hipokalsemia

 Faktor risiko:
a. Stres berat selama masa perinatal
b. Ibu penderita DM
c. Asupan nutrisi enteral ↓
d. Transfusi berulang
83 …Hipokalsemia

 Faktor risiko:
e. Alkalosis
f. Diuretik
g. Hiperparatiroid kongenital
h. Asupan magnesium rendah
i. Asupan fosfat berlebihan
84 …Hipokalsemia

 Gejala Klinis
Akut :
Apnea, iritabel, tremor ringan, tetani, kejang.
Gangguan hantaran jantung berupa aritmia dan Q-T memanjang
85 …Hipokalsemia

 Gejala Klinis
Kronis :
Rickets dengan demineralisasi tulang, epnea,
ALP  : fraktur iga dan tulang panjang
 …Hipokalsemia
86

 Tatalaksana:
2 – 4 mL/kgBB/hari larutan kalsium glukonas 10%
87 Masalah Infeksi Nosokomial (IN)

 Neonatus sangat rentan terhadap IN

 Penting diperhatikan cuci tangan prosedural
 Persiapan cairan parenteral
 Penggunaan ASI eksklusif
 Rasio pasien dan perawat
88 …masalah Infeksi Nosokomial (IN)

 Curiga IN pada:
 Ibu demam saat inpartu
 Keputihan berat
 Infeksi saluran kemih
 Ketuban pecah > 18 – 24 jam
89 Perdarahan pada Neonatus

 Buktikan bukan tertelan darah ibu (bayi aktif, merah)

 Pencegahan: injeksi vitamin K1, 1 mg IM
90 Kejang

 Bentuk subtle terbanyak

 Bedakan jittery dengan kejang
 Jittery (gemetaran): bila ekstremitas difleksikan gerakan stop
 Obat: luminal intravena
 Penyebab: hipoglikemia, hipokalsemia, perdarahan, meningitis, kelainan
struktur otak.
91 Kuning pada Bayi Baru Lahir

 Tentukan risiko rendah atau tinggi

 Faktor risiko:
 Prematur < 35 minggu
 Sakit
 Asfiksia
 Hemolisis:
 ABO inkompatibilitas
 Rhesus inkompatibilitas
 G6PD deficiency
 Hati-hati kuning pada 24 jam pertama atau > 2 minggu
 Metode Kramer
92 Metode Kramer
Zo Bagian tubuh Rata-rata bilirubin
na yang kuning indirek serum (umol/
L)
1 Kepala dan 100
leher
2 Pusat – leher 150

3 Pusat – paha 200

4 Leher + 250
tungkai
5 Tangan + kaki > 250
93 Cara Merujuk yang Baik

1. Sebaiknya transfer ibu hamil risiko tinggi ke fasilitas yang lengkap.

2. Bila terpaksa transfer bayi, pastikan suhu, pernapasan, dan sirkulasi stabil.
3. Metode kanguru.
 UPDATE IN NEONATAL
RESUSCITATION

Disampaikan pada keperawatan gawat

darurat 2 Prodi Keperawatan FK Untan
By. Ns. Maria Fudji Hastuti, M.Kep
 Introduction

 19% of 5 million neonatal deaths per year are caused by birth

asphyxia

 The outcome of 1 million newborns per year might be improved by

good resuscitation techniques
 …introduction

Newborns :
 90%  little to no assistance in initiating

respirations.
 10%  require some assistance to start breathing
at birth
 1%  need extensive resuscitation to survive
 …introduction

Resuscitation Procedure Diagram

Always needed Assess baby’s response to birth
by newborns Keep baby warm
Position, clear airway, stimulate to breathe
by drying, and give O2 (as necessary)

Establish effective ventilation

Needed less frequently Bag and mask
Endotracheal intubation

Provide chest compressions

Rarely needed by newborns
Administer
medications
 …introduction

ABCs of resuscitation
 Airway

 Breathing

 Circulation
 …introduction

Major concept in neonatal

resuscitation
 The most important and effective action in resuscitation is to
ventilate the baby’s lungs with oxygen.
Asphyxia and Depression

Normal infants at birth :

 Vigorous
 Initiate spontaneous respirations with crying
 Heart rate stabilizes at 120-140 bpm
 Initial central cyanosis clears rapidly
 …asphyxia

Depressed infants at birth :

 Decreased tone
 Difficulty initiating adequate respirations
 May be apneic or inadequate respiratory effort to establish sufficient
ventilation
 Limited O2 uptake and CO2 excretion
 Will develop increasing hypoxemia and will become progressively
asphyxiated
 …asphyxia

Causes for depression at birth

 Intrauterine asphyxia
 Prematurity
 Drugs administered to or taken by the mother
 Congenital neuromuscular diseases
 Congenital malformations
 Intrapartum hypoxemia
 …asphyxia

Asphyxia:
Denotes progressive hypoxia,
accumulation of CO2, and acidosis.
May result in permanent brain injury or
death
May affect the function of other vital
organs.
 How does a baby receive
oxygen before birth?
 Before birth, fetal O2 is come from the mother
 Fetal lungs are not functioning

 Alveoli are filled with fluid

 Blood vessels are constricted
 Blood from the right side of the heart  ductus arteriosus  aorta
Fluid-filled
alveoli and
constricted
blood
vessels in
the lung
before birth
Shunting of blood through the ductus arteriosus and
What normally happens at birth to allow
a baby to get oxygen from the lung

1. Fluid replaced by air in alveoli

air
Fetal
lung
fluid
air air

First Second Third

breath breath breath

Fluid replaced by air in alveoli

2. The umbilical arteries and vein are clamped. This increases systemic
blood pressure

3. Dilation of pulmonary blood vessels

This relaxation together with increased systemic blood pressure  increase

pulmonary blood flow and decrease flow through the ductus arteriosus
Dilation of pulmonary blood vessels at birth
Cessation of shunt
through ductus
arteriosus after birth, as
blood preferentially
flows to the lung
What can go wrong during transition?

 Not breath  lung will not fill with air & O2

 Lack of O2  sustained constriction of the pulmonary arterioles 

persistent pulmonary hypertension

 Blood loss, or poor cardiac contractility due to hypoxia  systemic

hypotension
Clinical findings of compromised
baby
Cyanosis
Bradycardia
Low blood pressure
Respiratory
depression
Poor muscle tone
 How to tell if a newborn had in utero
or perinatal compromise ?

After rapid breathing  period of primary

apnea  stimulation  breathing resumption
 if O2 deprivation continues  several
attempts to gasp  secondary apnea 
stimulation will not restart breathing  assisted
ventilation needed

Rapid (irregular
breathing gasping)
Primary
Secondary apnea
Apnea

Primary and secondary apnea

 Heart rate begins to fall in primary apnea. Blood pressure is
maintained until the onset of secondary apnea

Primary
apnea Secondary apnea

Heart rate

Time
Blood pressure

Time

Heart rate and blood pressure changes during apnea

Approximate time
Birth

 Clear of meconium ?
 Breathing or crying ?
 Good muscle tone ? Assessment
 Color pink ?
 Term gestation ?

30 seconds
No
 Provide warmth
 Position; clear airway* (as
necessary)
 Dry, stimulate, reposition A
 Give O2 (as necessary)

 Evaluate respirations, heart rate, and

color Evaluation
30 seconds

Apnea or HR < 100

 Provide VTP* B
HR < 60 HR > 60 Evaluation
 provide VTP*
30 sec.

 Administer chest compressions C

HR < 60 Evaluation
 Administer epinephrine*
D
Box A (airway)
 Provide warmth
 Positioning, clear airway

Then nose

Suctioning the mouth and nose: “M” before “N”

 …box A
 Dry, stimulate to breathe, and reposition
 …kotak A
 Deliver free-flow oxygen as necessary

O2 mask held close to the O2 delivered by tubing held in

baby’s face to give close to cupped hand over baby’s face
100% O2
 Box B (respirations)
Provide positive-pressure ventilation with a bag
and mask for 30 seconds
 Types of resuscitation bags :

Self-inflating bag & flow-inflating bag

Regulation
of O2 and
pressure in
flow-
inflating Setting a
bag self-
inflating
bag
 …box B

 Positioning bag and mask on

the face
 …box B
 Bag size and pressures:

Illustrative pressures
• Initial breath after
delivery : > 30 cm H2O
• Normal lungs (later
breaths) : 15-20 cm
H2O
• Diseased or immature
lungs : 20-40 cm H2O

Relative sizes of a normal breath and common resuscitation bags

 …box B

 Positive-pressure ventilation is stopped if :

Increasing heart rate

Improving color
Spontaneous breathing

 If bag and mask ventilation is to be continued for more than several minutes,
insert orogastric tube and left in place.
Endotracheal intubation equipments

Endotracheal tubes with uniform

diameter are preferred for
newborns

Neonatal resuscitation equipment and supplies

 Process of cutting endotracheal tube to
length before insertion

Characteristics of endotracheal tubes

used for neonatal resuscitation

Optional stylet for increasing endotracheal tube

stiffness and maintaining curvature during
 Box C (circulation)

 Increase heart rate by starting chest compression while

simultaneously continue ventilating for 30 seconds.

Chest compression :
–Require 2 persons
–2 techniques :
•thumb
•Two-finger
Correct method of chest
compressions (fingers remain in
contact with chest on release
 …box C
Chest compression :

 Position  lower third of the sternum

 Pressure  ± 1/3 diameter anterior-posterior of the chest
 Frequent  1 ventilasi interposed after 3 compression, for total of
30 breaths & 90 compressions per minute
 Discontinue if HR > 60 x/minute
 Box D (medications)

Administer epinephrine as coordinated chest

compression and ventilation are continues
A. Epinephrine :

 cardiac contractions
Peripheral vasoconstriction   blood
flow through the coronary arteries and
to the brain.
Routes : through endotracheal
tube or intravenously
Dose : 0,1 – 0,3 mL/kg of 1 : 10.000
solution
(0,01 – 0,03 mg/kg)
Rate : rapidly, as quickly as possible
 …box D

B. NaCl 0,9%
Abruptio placentae
Placenta previa
Blood loss from umbilical cord

Hypovolemik shock  pale, weak pulses  give

normal saline 10 ml/kg IV over 5 – 10 minutes.
 …box D

C. Sodium bicarbonate

Metabolic acidosis

Sodium bicarbonate 2 mEq/kg (4 ml/kg of

4,2% solution), through umbilical vein
slowly, no faster than a rate of 1 mEq/kg/min.
 …box D
D. Naloxone hydrochloride

Indication :
 Severe respiratory depresiion with a normal heart rate and color after PPV
 A history of maternal narcotic administration within the past 4 hours

Concentration :
 1 mg/mL solution

Route :
 ET, IV, IM, or SC

Dose : 0,1 mg/kg

 HR < 60 x/min after being given epinephrine :
Recheck effectiveness of
• Ventilation
• Chest compression
• Endotracheal intubation HR= 0 Consider to stop
• Epinephrine delivery
resuscitation
Consider possibility of
• Hypovolemia
• Severe metabolic acidosis

HR < 60 or persistent cyanosis or failure to ventilate

Consider
• Depressed respiratory
neuromuscular drive
• Airway malformations
• Lung problems, such as :
– Pneumothorax
– Diaphragmatic hernia
• Congenital heart disease
How to prioritize actions ?

Cycle repeated throughout resuscitation:

Evaluation newborn
Decide on what actions to take
Taking action

Evaluation is based primarily on:

Respirations
Heart rate
Color
 Why is the Apgar score not used
during resuscitation ?
Apgar score :
 Quantifying the newborn’s condition, giving information about the
newborn’s overall status and response to resuscitation

 Not used to determine :

The need for resuscitation

What resuscitation steps are
necessary, or when to use them
 Why is the Apgar score not used
during resuscitation ?
 Resuscitation must be initiated before the score is assigned
 Normally assigned at 1 minute and again at 5 minute of age. When
the 5-minute apgar < 7  additional score every 5 minutes for up to
20 minutes
 How do you prepare for a
resuscitation
 Every birth should be attended by at least 1 person skilled in neonatal resuscitation

 If you anticipate the possible need for neonatal resuscitation (high risk delivery)

1. Recruit additional skilled personal to be present

2. Prepare the necessary equipment

What risk factors are associated with
the need for neonatal resuscitation

 Antepartum factors

 Intrapartum factors
 Antepartum factors
 Maternal diabetes
 Pregnancy-induced hypertension
 Chronic hypertension
 Anemia / isoimmunization
 Previous fatal or neonatal death
 Bleeding in second or third semester
 maternal infection
 Maternal cardiac, renal, pulmonary, •
thyroid, or neurologic disease
 Polyhydramnios
 Oligohydramnios
…risk factors
• Premature rupture of membranes
• Post-term gestation
• Multiple gestation
• Size-dates discrepancy
• Drug therapy, eq. Lithium carbonate,
magnesium, Adrenergic-blocking
drug
Maternal substance abuse
• Fetal malformation
• Diminished fetal activity
• No prenatal care
• Age < 16 or > 35 tahun
 Intrapartum factors
 Emergency cesaream section
 Forceps or vacuum assisted delivery •
 Breech or other abnormal
presentation
 Premature labor
 Precipitous labor
 Chorioamnionitis
 Prolonged rupture or membranes
(>18 hours before delivery)
 Prolonged labor (>24 hours)
 Prolonged second stage of labor
(>2 hours)
…risk factors
• Fetal bradycardia
Non-reassuring fetal heart rate
patterns
• Use of general anesthesia
• Uterine tetany
• Narcotics administered to mother
within 4 hours of delivery
• Meconium-stained amniotic fluid
• Prolapsed cord
• Abruptio placentae
• Placenta previa
What personnel should be present
at delivery ?

 A person who is capable of performing complete resuscitation

correctly.
 At least 2 persons for anticipated high risk delivery.
 The concept of a resuscitation team
 Resuscitation equipment

 Suction equipment
 Bag-and-mask equipment

 Intubation equipment
 Medications
 Miscellaneous (gloves, clock, warmed linens)
COME WE DISCUSS TOGETHER

 ASUHAN KEPERAWATAN
 NURSING CRITICAL CARE