ASUHAN KEPERAWATAN KRITIS/EMERGENCY

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

A. PENGKAJIAN
Tanggal Masuk

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Tanggal Pengkajian

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I. Identitas Klien
Nama

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Umur

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Jenis Kelamin

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Alamat

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Diagnosa Medis

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No. RM

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II. Identitas Penanggung Jawab
Nama

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Umur

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Jenis Kelamin

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Alamat

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Hub. Dengan Klien

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a. PRIMARY SURVEY
 CIRCULATION
Nadi :

Teraba

Tidak terbara

Nadi :......X/Menit,
Perdarahan :

Irama nadi :

Ada

Ya

Tidak teratur

Tidak ada, tempat perdarahan :.................................

Perfusi / CRT :......
Sianosis :

Teratur

Tidak

Tekanan Darah : ..............mmHg
Suara Jantung :.............................

..... Tidak ada tidak Pin Medriasis........ Papil edema : Ada Lateralisasi : ya............. Mata :....... dulness  DISABILITY Kesadaran : Alert Kesadaran : Composmentis GCS Verbal respon Apatis Pain respon Somnolent Unresponsible Sopor Coma : . hipersonor.... tidak simetris Retraksi intercosta Jejas di dada Cuping hidung Distensi vena leher Luka terbuka di dada Listen ( Mendengarkan suara pernafasan ) Vesikuler Bronkhovesikuler Whezzing Ronchi Bronkhial Krekles Trakheal Stridor Feel ( Meraba ) Krepitasi Perkusi : Nyeri tekan Sonor...... AIRWAY Look ( Melihat obstruksi jalan nafas ) Obstruksi jalan nafas : Ada Tidak ada Jika 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 :..... Pupil : Isokor Miosis cahaya :...  BREATHING Look (Lihat pergerakan dada) Pengembangan dada : Sesak nafas Simetris.............................. Motorik :....... reaksi terhadap ............ Verbal :..............

..  Keluhan .................................................. Kelainan bentuk :....................................................... tidak ada................................ Suhu : ......................................................................... b.................................................................................................................. ...........................................................................  Anamnesa ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ……………………………...... ada................. Nyeri :................. tempat jejas :......................  Heart monitoring dan oxymetri .................................................................................. tempat lesi :... SECUNDERY SURVEY  Keadaan Umum Tekanan Darah : ....................... ....... tidak ada..........................  Folley cateter ..................................................................................... ........................................................................................................................................................... Nadi : ................................ EXPOSURE Jejas : Lesi : ada................  Gastric tube ................... RR : .........................................................................................................................................

................................................................................................................ ....................................................  Kontusio :............. .......................................................................................................................  Luka termal :.......................................................................................................... ............................................................................................................................... ......................... ............................................................................................... Obat-obatan ........................................................................................................... Lubang anus :............. Lubang telinga :............ ...................................................  Alergi ...................................................... ....................................................................................................................................................................................................................................................................................................................................... ..................................................  Tubes and finger in every orifice Lubang hidung :............................................................................................................................................................................. ............. .......................................  Kejadian ................................... ................................................................................... ....................................................................................  Pemeriksaan kulit kepala Inspeksi :  Laserasi : ................................  Penyakit penyerta .......................  Perdarahan :............................................................................................................................................... ............................................................................................................................................................................................................................................................................................................................  Makanan .............................................................................................................. Lubang vagina :.....................................................

............................................................  Krepitasi / fraktur :...  Wajah  Mata Inspeksi :  Cornea :...........................................................  Racon eyes:..............................................................................................  Pembengkakan :.........................  Deformitas :.....  Vertebra servikalis / Leher Inspeksi  Jejas :..........Palpasi :  Nyeri tekan :.....................................................................................  Hemotimpanium :..  Rahang bawah  Stabilitas rahang :..............  Fraktur :..........................  Tanda batle sign :.......  Krepitasi / fraktur :....  Krepitasi / fraktur :...................................  Krepitasi / fraktur :......................................  Rahang atas  Stabilitas rahang :.  Deformitas :........  Pembengkakan :..................  Hidung  Pembengkakan :.........................................................  Telinga  Keutuhan membrantimpani :.....................  Pupil :............. ..........  Zygoma  Pembengkakan :.............

...  Pembengkakan :...........................  Perkusi :................  Pembengkakan :..............................  Luka terbuka :...............................................................................  Palpasi :...............................  Torak  Jejas :..............................  Jejas :...............  Palpasi :....  Pemakaian otot pernafasan tambahan :........  Perkusi :....................................................  Perkusi :...................  Auskultasi :........................  Nyeri tekan :............................................................................................................................................  Palpasi :.... Deviasi trakhea....  Krepitasi :........................  Auskultasi :......... ....................................................................................................  Jantung  Inspeksi :..  Auskultasi :............................................................................................................................................  Deformitas :........................ Palpasi  Nyeri tekan :...........  Nyeri tekan :...................  Pelvis  Kestabilan posisi :.....  Abdomen  Inspeksi :................................  Paru-paru  Inspeksi :.................

 Pembengkakan :................................................................................................................................................................................................................... ....................  Deformitas :................................................................................................................................................................................... .................................................................................................................................................................................................................................................  Ekstremitas Inspeksi :  Laserasi :.........................................................  Punggung  Jejas :........................... ........................................................................................................  Nyeri tekan :................................................................................................ ......... PEMERIKSAAN DIAGNOSTIK  Pemeriksaan Laboratorium .......................................... Palpasi :  Nyeri tekan :...................................... Krepitasi / fraktur :.................................................... ......................... ..........................................................................................................  Fraktur :....................................... ......................  Pembengkakan :....................................................................................................................................... ......................................................................... ...........  Kekuatan otot :.....  Perdarahan :...........................  Deformitas :..................................................................... ...........................................................................  Pemeriksaan Rotgen ....................................................................................................................  Deformitas :....................................... c..............  Krepitasi :..

........................................................................... ......................................................................... ..... ......................................  Pemeriksaan yang lain ................................................................ .............. ............................................................................................................... ..............................................................................................................................  Pemeriksaan EKG ............................................ .................. ............................................................................................................................................................................................................................................................................................. ..................................... ..................................................................... .............................................................................. ...................................................... ......................................................  Pemeriksaan CTScan/MRI .................................................................... .....................................................................................................................................................  Pemeriksaan USG .................................................................................................................................................................................................................................................................................................................................................................................................. ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................... . ......................  Therapy ......................................................................................................................................................................................................................... ..................................................................

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