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Published by: Petruz Dominggo Riberu on Apr 15, 2013
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07/20/2015

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ASUHAN KEPERAWATAN KRITIS/EMERGENCY

PADA Tn/Ny……DENGAN…………………..DISERTAI ……………
DI RUANG IGD RSUD DR MOEWARDI SURAKARTA

A. PENGKAJIAN
Tanggal Masuk :.................................................
Tanggal Pengkajian : ……………………………….

I. Identitas Klien
Nama : ……………………………….
Umur : ……………………………….
Jenis Kelamin : ……………………………….
Alamat : .................................................
Diagnosa Medis :..................................................
No. RM : .................................................

II. Identitas Penanggung Jawab
Nama : .................................................
Umur : .................................................
Jenis Kelamin : .................................................
Alamat : .................................................
Hub. Dengan Klien : .................................................

a. PRIMARY SURVEY
 CIRCULATION
Nadi : Teraba Tidak terbara
Nadi :......X/Menit, Irama nadi : Teratur Tidak teratur
Perdarahan : Ada Tidak ada, tempat perdarahan :.................................
Perfusi / CRT :......
Sianosis : Ya Tidak
Tekanan Darah : ..............mmHg
Suara Jantung :.............................

 AIRWAY
Look ( Melihat obstruksi jalan nafas )
Obstruksi jalan nafas : Ada Tidak ada
J ika ada berupa :
Sekret Darah Benda asing Lidah jatuh ke belakang
Listen ( Mendengarkan suara jalan nafas )
Gurgling Snoring Crowing
Feel ( Meraba )
Hembusan udara : Hidung Mulut
Deviasi trakhea :....................................
 BREATHING
Look (Lihat pergerakan dada)
Pengembangan dada : Simetris, tidak simetris
Sesak nafas Retraksi intercosta Cuping hidung Distensi vena leher
Jejas di dada Luka terbuka di dada
Listen ( Mendengarkan suara pernafasan )
Vesikuler Bronkhovesikuler Bronkhial Trakheal
Whezzing Ronchi Krekles Stridor
Feel ( Meraba )
Krepitasi Nyeri tekan
Perkusi : Sonor, hipersonor, dulness
 DISABILITY
Kesadaran : Alert Verbal respon Pain respon Unresponsible
Kesadaran : Composmentis Apatis Somnolent Sopor Coma
GCS : ..............
Mata :............, Motorik :..........., Verbal :...........
Pupil : Isokor Miosis Pin Medriasis, reaksi terhadap
cahaya :.......................
Papil edema : Ada Tidak ada
Lateralisasi : ya, tidak



 EXPOSURE
Jejas : ada, tidak ada, tempat jejas :......................................................
Lesi : ada, tidak ada, tempat lesi :..........................................
Kelainan bentuk :....................................
Nyeri :............................
 Folley cateter
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 Gastric tube
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 Heart monitoring dan oxymetri
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b. SECUNDERY SURVEY
 Keadaan Umum
Tekanan Darah : .........................................
Nadi : .........................................
RR : .........................................
Suhu : .........................................
 Anamnesa
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 Keluhan
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 Obat-obatan
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 Makanan
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 Penyakit penyerta
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 Alergi
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 Kejadian
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 Tubes and finger in every orifice
Lubang hidung :..........................
Lubang telinga :..........................
Lubang anus :..............................
Lubang vagina :..............................
 Pemeriksaan kulit kepala
Inspeksi :
 Laserasi : ............................
 Kontusio :............................
 Luka termal :..........................
 Perdarahan :...............................
Palpasi :
 Nyeri tekan :...............................
 Fraktur :......................................
 Wajah
 Mata
Inspeksi :
 Cornea :.................................
 Pupil :...................................
 Racon eyes:..........................
 Hidung
 Pembengkakan :.................................
 Krepitasi / fraktur :............................
 Zygoma
 Pembengkakan :.................................
 Krepitasi / fraktur :...........................
 Telinga
 Keutuhan membrantimpani :...........................
 Hemotimpanium :..............................
 Tanda batle sign :................................
 Rahang atas
 Stabilitas rahang :........................
 Krepitasi / fraktur :.........................
 Pembengkakan :............................
 Deformitas :..................................
 Rahang bawah
 Stabilitas rahang :........................
 Krepitasi / fraktur :.......................
 Pembengkakan :...........................
 Deformitas :.................................
 Vertebra servikalis / Leher
Inspeksi
 Jejas :................
 Deviasi trakhea....................
 Pemakaian otot pernafasan tambahan :...........................
Palpasi
 Nyeri tekan :...........................
 Deformitas :.............................
 Pembengkakan :..........................
 Torak
 Jejas :.......................
 Luka terbuka :.................
 Nyeri tekan :........................
 Krepitasi :.................................

 Paru-paru
 Inspeksi :........................................
 Palpasi :.........................................
 Perkusi :..........................................
 Auskultasi :.....................................
 Jantung
 Inspeksi :......................................
 Palpasi :........................................
 Perkusi :.........................................
 Auskultasi :...................................
 Abdomen
 Inspeksi :............................................
 Auskultasi :........................................
 Perkusi :.............................................
 Palpasi :..............................................
 Pelvis
 Kestabilan posisi :..............................
 Jejas :..................................................
 Nyeri tekan :........................................
 Pembengkakan :.................................
 Krepitasi / fraktur :............................
 Deformitas :.........................................
 Ekstremitas
Inspeksi :
 Laserasi :.....................................
 Perdarahan :...............................
 Pembengkakan :............................
 Deformitas :..................................
Palpasi :
 Nyeri tekan :...............................
 Krepitasi :...................................
 Kekuatan otot :...............................
 Punggung
 Jejas :............................
 Pembengkakan :.........................
 Deformitas :...............................
 Nyeri tekan :..............................
 Fraktur :....................................

c. PEMERIKSAAN DIAGNOSTIK
 Pemeriksaan Laboratorium
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 Pemeriksaan Rotgen
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 Pemeriksaan EKG
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 Pemeriksaan CTScan/MRI
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 Pemeriksaan USG
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 Pemeriksaan yang lain
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 Therapy
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........ Verbal :......... Motorik :........... hipersonor................... Pupil : Isokor Miosis Pin Medriasis..... Retraksi intercosta Luka terbuka di dada Listen ( Mendengarkan suara pernafasan ) Vesikuler Whezzing Feel ( Meraba ) Krepitasi Perkusi :  DISABILITY Kesadaran : Kesadaran : GCS Alert Verbal respon Apatis Pain respon Somnolent Unresponsible Sopor Coma Nyeri tekan Sonor.... AIRWAY Look ( Melihat obstruksi jalan nafas ) Obstruksi jalan nafas : Jika ada berupa : Sekret Darah Benda asing Lidah jatuh ke belakang Ada Tidak ada Listen ( Mendengarkan suara jalan nafas ) Gurgling Feel ( Meraba ) Hembusan udara :  BREATHING Look (Lihat pergerakan dada) Pengembangan dada : Sesak nafas Jejas di dada Simetris..... Mata :..... Papil edema : Lateralisasi : Ada ya.................. reaksi terhadap cahaya :. Tidak ada tidak .. tidak simetris Cuping hidung Distensi vena leher Hidung Mulut Snoring Crowing Deviasi trakhea :....... dulness Bronkhovesikuler Ronchi Krekles Bronkhial Stridor Trakheal Composmentis : .....................

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