FORMAT PENGKAJIAN KEPERAWATAN

GAWAT DARURAT
Nama Mahasiswa
Semester/Tingkat
Tempat Praktek
Tanggal Pengkajian

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DATA KLIEN

A. DATA UMUM
1. Nama inisial klien
2. Umur
3. Alamat
4. Agama
5. Tanggal masuk RS/RB
6. Nomor Rekam Medis
7. Bangsal

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B. PENGKAJIAN PRIMER:
1. Airway (jalan nafas)
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2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, bantuan nafas, dll)
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b. Palpasi (total fremitus, dll)
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c. Perkusi (pembesaran paru, dll)
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d. Auskultasi (suara nafas)
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3. Circulation
a. Vital sign:
1) Tekanan darah :
2) Nadi
:
3) Suhu
:
4) Respirasi
:
b. Capilarry refill
:
c. Akral
:
4. Disability
a. GCS
E: .....
M: ........
b. Pupil
:
c. Gangguan motorik :

V: ......

d. Gangguan sensorik :
C. PENGKAJIAN 13 DOMAIN NANDA
1. HEALTH PROMOTION
a. Kesehatan Umum:
- Alasan masuk rumah sakit/keluhan utama:
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b. Riwayat masa lalu (penyakit, kecelakaan,dll):
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c. Riwayat pengobatan
No Nama obat/jamu
Dosis
Keterangan
1.
2.
3.
d. Kemampuan mengontrol kesehatan:
- Yang dilakukan bila sakit : .........................................................................
- Pola hidup (konsumsi/alkohol/olah raga, dll)
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e. Faktor sosial ekonomi (penghasilan/asuransi kesehatan, dll):
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f. Pengobatan sekarang:
No Nama obat
Dosis
Kandungan
Manfaat
1.
2.
3.
4.
2. NUTRITION
a. A (Antropometri) meliputi BB, TB, LK, LD, LILA, IMT:
1) BB biasanya: .............. dan BB sekarang: ............
2) Lingkar perut
:
3) Lingkar kepala
:
4) Lingkar dada
:
5) Lingkar lengan atas :
6) IMT
:
b. B (Biochemical) meliputi data laboratorium yang abormal:
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c. C (Clinical) meliputi tanda-tanda klinis rambut, turgor kulit, mukosa bibir,
conjungtiva anemis/tidak:
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d. D (Diet) meliputi nafsu, jenis, frekuensi makanan yang diberikan selama di

rumah sakit:
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e. E (Enegy) meliputi kemampuan klien dalam beraktifitas selama di rumah
sakit:
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f. F (Factor) meliputi penyebab masalah nutrisi: (kemampuan menelan,
mengunyah,dll)
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g. Penilaian Status Gizi
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h. Pola asupan cairan
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i. Cairan masuk
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j. Cairan keluar
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k. Penilaian Status Cairan (balance cairan)
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l. Pemeriksaan Abdomen
Inspeksi :
Auskultasi :
Palpasi
:
Perkusi
:

3. ELIMINATION
a. Sistem Urinary
1) Pola pembuangan urine (Frekuensi , jumlah, ketidaknyamanan)
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2) Riwayat kelainan kandung kemih

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3) Pola urine (jumlah, warna, kekentalan, bau)
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4) Distensi kandung kemih/retensi urine
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b. Sistem Gastrointestinal
1) Pola eliminasi
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2) Konstipasi dan faktor penyebab konstipasi
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c. Sistem Integument
1) Kulit (integritas kulit / hidrasi/ turgor /warna/suhu)
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4. ACTIVITY/REST
a. Istirahat/tidur
1) Jam tidur
:
2) Insomnia
:
3) Pertolongan untuk merangsang tidur:
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b. Aktivitas
1) Pekerjaan
:
2) Kebiasaan olah raga :
3) ADL
a) Makan
:
b) Toileting
:
c) Kebersihan
:
d) Berpakaian
:
4) Bantuan ADL
:
5) Kekuatan otot
:
6) ROM
:
7) Resiko untuk cidera :
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c. Cardio respons
1) Penyakit jantung
:
2) Edema esktremitas :
3) Tekanan vena jugularis:

4) Pemeriksaan jantung
a) Inspeksi
b) Palpasi
c) Perkusi
d) Auskultasi

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:
:
:

d. Pulmonary respon
1) Penyakit sistem nafas :
2) Penggunaan O2
:
3) Kemampuan bernafas :
4) Gangguan pernafasan (batuk, suara nafas, sputum, dll)
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5) Pemeriksaan paru-paru
a) Inspeksi
:
b) Palpasi
:
c) Perkusi
:
d) Auskultasi
:
5. PERCEPTION/COGNITION
a. Orientasi/kognisi
1) Tingkat pendidikan
:
2) Kurang pengetahuan
:
3) Pengetahuan tentang penyakit:
4) Orientasi (waktu, tempat, orang)
b. Sensasi/persepi
1) Riwayat penyakit jantung
:
2) Sakit kepala
:
3) Penggunaan alat bantu
:
4) Penginderaan
:
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c. Communication
1) Bahasa yang digunakan
2) Kesulitan berkomunikasi

:
:

6. SELF PERCEPTION
a. Self-concept/self-esteem
1) Perasaan cemas/takut
:
2) Perasaan putus asa/kehilangan:
3) Keinginan untuk mencederai :
4) Adanya luka/cacat
:

7. ROLE RELATIONSHIP
a. Peranan hubungan
1) Status hubungan
2) Orang terdekat
3) Perubahan konflik/peran
4) Perubahan gaya hidup

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5) Interaksi dengan orang lain

8. SEXUALITY
a. Identitas seksual
1) Masalah/disfungsi seksual

9. COPING/STRESS TOLERANCE
a. Coping respon
1) Rasa sedih/takut/cemas
:
2) Kemampan untuk mengatasi :
3) Perilaku yang menampakkan cemas ;
10. LIFE PRINCIPLES
a. Nilai kepercayaan
1) Kegiatan keagamaan yang diikuti
2) Kemampuan untuk berpartisipasi
3) Kegiatan kebudayaan
4) Kemampuan memecahkan masalah

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11. SAFETY/PROTECTION
a. Alergi
:
b. Penyakit autoimune
:
c. Tanda infeksi
:
d. Gangguan thermoregulasi
:
e. Gangguan/resiko (komplikasi immobilisasi, jatuh, aspirasi, disfungsi
neurovaskuler peripheral, kondisi hipertensi, pendarahan, hipoglikemia,
Sindrome disuse, gaya hidup yang tetap)
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12. COMFORT
a. Kenyamanan/Nyeri
1) Provokes (yang menimbulkan nyeri)
2) Quality (bagaimana kualitasnya)
3) Regio (dimana letaknya)
4) Scala (berapa skalanya)
5) Time (waktu)
b. Rasa tidak nyaman lainnya
c. Gejala yang menyertai

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13. GROWTH/DEVELOPMENT
a. Pertumbuhan dan perkembangan
:
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D. DATA LABORATORIUM

Tanggal &
Jam

Jenis
Pemeriksaan

Hasil
Pemeriksaan

Harga
Normal

Satuan

Interpretasi