STIKES NANI HASANUDDIN MAKASSAR

PROGRAM PROFESI NERS

FORMAT RESUME KASUS

KEPERAWATAN GAWAT DARURAT
(DI INSTALASI RAWAT DARURAT)

I.

Tgl Masuk Rumah Sakit

: .............................

Jam

: .............................

Nomor Register

: .............................

Bedah/Non bedah

: .............................

Diagnosa Medis

: .............................

BIODATA
A. Identitas Pasien
1. Nama Lengkap
2. Jenis Kelamin
3. Umur / Tanggal Lahir
4. Kawin / Belum Kawin
5. A g a m a
6. Suku / Bangsa
7. Pendidikan
8. Pendapatan
9. Pekerjaan
10. Nomor Askes
11. Alamat

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B. Identitas Keluarga/Pengantar
1. Nama Lengkap
2. Jenis Kelamin
3. Umur / Tanggal Lahir
4. A g a m a
5. Suku / Bangsa
6. Pendidikan
7. Pendapatan
8. Pekerjaan
9. Hubungan dengan pasien
10. Alamat

:
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II.

RIWAYAT KESEHATAN
A. Keluhan Masuk
: ................................................................................
............................................................................................................................. ........
B. Riwayat Keluhan Masuk
: ................................................................................
................................................................................................................................ ..dst
C. Survey Primer
1. ABCDE
Airway :
- Apakah ada tanda-tanda sumbatan jalan nafas : ......................................................
- Apakah terdengar bunyi stridor : ..........................................................................
- Apakah ada tanda-tanda keberadaan benda asing, darah, muntah dalam mulut ....
- Apakah jalan napas paten : .................................................................................
Diagnosa Keperawatan :
............................................................................................................................. ...........
............................................................................................................................. ...
Rencana Tindakan :
Tujuan : ................................................................................................... ..................
............................................................................................................................. ...
Intervensi :
1. ............................................................................................................................
2. ............................................................................................................................
3. dst.
Implementasi :
Jam ............
1. ............................................................................................................................
Jam .............
2. Dst
Evaluasi :
Jam : ............
S : ..................................................................
O : ..................................................................
A : ..................................................................
P : ..................................................................

Breathing
-

Apakah ada hembusan udara dr hidung (feel) ?

- Pengembangan dada (look) ?

- Apakah terdengar suara napas (listen) ?
- Frekuensi napas
- Retraksi intercostal
- Bunyi napas
: (ngorok, bersiul, megap, dll)
- Penggunaan otot-otot aksesori pernapasan
- Suara napas tambahan
: Ronchi, wheezing, Rales, dll
Diagnosa Keperawatan :
............................................................................................................................. ...........
........................................................................................................................ ........
Rencana Tindakan :
Tujuan : .................................................................................................................... .
..................................................................................................... ...........................
Intervensi :
1. ............................................................................................................................
2. ............................................................................................................................
3. dst.
Implementasi :
Jam ............
1. ............................................................................................................................
Jam .............
2. Dst
Evaluasi :
Jam : .............
S : ..................................................................
O : ..................................................................
A : ..................................................................
P : ..................................................................

Circulation
-

Apakah ada perdarahan/tidak ?

Apakah ada pulsa karotis, nadi radial ?
Apakah nadi teraba/tidak ?
Kualitas nadi
: lemah/kuat/kecil
Akral
: Hangat/dingin
Pengisian kapiler
: < 3 detik / > 3 detik
Apakah ada tanda-tanda syok : nadi lemah dan cepat? Nadi lebih dari 100x/menit
pada dewasa?
Apakah kulit teraba dingin/hangat?
Apakah kulit tampak pucat atau kebiru-biruan?
Apakah pasien tidak sadar atau nampak mengantuk?

Diagnosa Keperawatan :
............................................................................................................................. ...........
........................................................................................................................ ........
Rencana Tindakan :
Tujuan : .................................................................................................................... .
..................................................................................................... ...........................
Intervensi :
1. ............................................................................................................................
2. ............................................................................................................................
3. dst.
Implementasi :
Jam ............
1. ............................................................................................................................
Jam .............
2. Dst
Evaluasi :
Jam : ...........
S : ..................................................................
O : ..................................................................
A : ..................................................................
P : ..................................................................

Disability ; gunakan AVPU

-

A Alert (jaga) apakah klien mengerti apa yang anda sampaikan?

V Voice (suara) apakah mereka bisa berbicara pada anda?
P Pain (nyeri) apakah klien berespon terhadap nyeri?
U Unresponsive (tidak berespon) apakah pasien tidak sadar atau tidak berespon?
Cek ukuran pupil, apakah ukuran sama/tidak, apakah bereaksi terhadap cahaya
(mengecil).
- GCS (Glasgow Coma Scale)
Diagnosa Keperawatan :
........................................................................................................................................
............................................................................................................................. ...
Rencana Tindakan :
Tujuan : .....................................................................................................................
............................................................................................................................. ...

Intervensi :
1. ............................................................................................................................
2. ............................................................................................................................
3. dst.
Implementasi :
Jam ............
1. ............................................................................................................................
Jam .............
2. Dst
Evaluasi :
Jam : .............
S : ..................................................................
O : ..................................................................
A : ..................................................................
P : ..................................................................

D. Survey Sekunder
1. AMPLE
a. Allergies (alergi)
: ....................................................................................................
b. Medication (obat-obatan) : ..................................................................................
...........................................................................................................................
c. Past history (riwayat singkat penyakit, kecelakaan, tindakan pembedahan, dan
perawatan selama sakit. : ........ .......... ............. ............ ............. ............. ......... .....
.................................................................................................. ........................
d. Last time ate or drank (waktu terakhir makan dan minum) : ........ .......... .............
...........................................................................................................................
e. Event (apa yang menyebabkan terjadinya kecelakaan? Kecelakaan kendaraan, luka
bakar, dll
: .....................................................................................................
.................................................................................................. ........................
2. PEMERIKSAAN FISIK (EKSPOSURE)
a. Keadaan umum .........................................................................................................:
b. TTV
:
Tekanan darah : .........................................
Nadi

: .........................................

Pernapasan : .........................................
Suhu

: .........................................

3. Berat Badan : ...........................................................................................................

4. Tinggi Badan : ...........................................................................................................
5. Kepala
- Reaksi pupil terhadap cahaya, ukuran : ..................................

Apakah ada luka? Deformitas/cacat?, memar, pembengkakan, tulang yang

penyek ke dalam : ...........................................................................................
Apakah ada cairan yang keluar dari telinga atau hidung ? : ................................
.............................................................................................................................
Periksa adanya nyeri tekan .............................................................................
Ukur Glasgow Coma Scale :
Eye (Mata) : ............... (.................................................................................)
M (Motorik: .......... (..................................................................................... ...)
V (Verbal) : .......... (........................................................................................)
Jumlah skor: .......... (....................................................)

6. Leher
- Tanda-tanda injury spinal : ..................................................................................
- Apakah ada luka? Deformitas? Memar? Dan pembengkakan? : ............................
- Apakah ada distensi/penggembungan dari vena leher? ........................................
- Perhatikan posisi trakhea apakah ditengah-tengah atau terdorong ke salah satu
sisi .......................................................................................................................
- Rasakan apakah ada udara di bawah kulit (empisema subkutan)..........................
7. Dada
- Hasil pemeriksaan EKG : ....................................................................................
- Kecepatan nafas : ...............x/menit, upaya nafas : .........................................
- Pengembangan dada (simetris/tidak) : ...............................................................
- Apakah ada luka, deformitas, memar, bengkak, atau depresi tulang (tulang
masuk ke dalam) .................................................................................................
- Bunyi napas : ............................................ kiri/kanan : ..................................
8. Perut
- Apakah ada luka, memar, bengkak pada kulit, atau pembesaran pada seluruh
perut (distensi) ............................................................................................
- Apakah ada skar (bekas luka) yang lama : ........................................................
- Bising usus : ................................. pristaltik usus : .............x/menit
- Nyeri pada kuadran abdomen : ...................................................., kekakuan : ....
.............................., atau tampak sikap menjaga area perut yang mengindikasi
perdarahan pada perut.

9. Pelvis, Rektum dan Genital

- Apakah ada luka, deformitas, atau memar?..........................................................
- Apakah ada perdarahan dari urethra?..................................................................
- Apakah
ada
perdarahan
sekitar
skrotum,
rektum,
atau
vagina?..........................................................................................................
- Apakah ada fraktur atau dislokasi?...................................................................
10. Lengan dan tungkai
- Apakah ada luka, deformitas, memar, atau pembengkakan?............................
- Apakah ada nyeri tekan? Apakah pasien dapat merasakan sensasi sentuhan
yang anda lakukan? Pergerakan sendi?............................................................
- Nadi perifer ada/tidak?
- Suhu anggota gerak, tangan, dan kaki? Panas atau dingin?.............................
11. Punggung
- Apakah ada luka, deformitas, memar, pembengkakan, depresi tulang?................
- Apakah ada perdarahan yang berasal dari anus?.............................................
- Apakah ada nyeri tekan?.................................................................................

III.

PEMERIKSAAN DIAGNOSTIK
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IV.

DATA LAIN-LAIN YANG DIANGGAP PERLU

........................................................................................................................................
............................................................................................................................. ...........
PERAWATAN/PENGOBATAN
1. Perawatan
Tindakan perawatan yang diberikan ..........................................................................
............................................................................................................................. ......
2. Pengobatan
Tindakan
pengobatan
yang
diberikan..............................................................
............................................................................................................................. ......

Diagnosa Keperawatan (dari survey sekunder) :

............................................................................................................................. ...........
.................................................................................................. ..............................
Rencana Tindakan :
Tujuan : .................................................................................................................... .
................................................................................................................................
Intervensi :
1. ............................................................................................................................
2. ............................................................................................................................
3. dst.
Implementasi :
Jam ............
1. ............................................................................................................................
Jam .............
2. Dst

Evaluasi :

Jam : .............
S : ..................................................................
O : ..................................................................
A : ..................................................................
P : ..................................................................

Dst, dituliskan semua diagnosa yang muncul pada survey sekunder.

DISCHARGE PLANNING
(PERENCANAAN PULANG/TINDAK LANJUT RAWAT INAP)

S
(subjektif)
O
(objektif)
A
(analisis)
P
(planning)
I
(implementasi)
E
(evaluasi)

Nama pasien ............................... L/P, masuk rumah sakit pada tanggal .............. jam.......................
dengan diagnosa medis ............................. telah diberikan tindakan keperawatan di atas. Untuk itu
perlu perawatan lanjutan di ..................... .............................../ kunjungan rutin ke ..............................
mulai tgl ..................

Terapi obat yang diberikan :

Anjuran

Keterangan

Makassar, ...........................................2009

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