ASUHAN KEPERAWATAN GAWAT DARURAT

Nama/Usia
Jenis kelamin
Alamat
Nomor register
MRS
Tanggal Pengkajian
Diagnosa medis
Keluhan

Keadaan Umum

:
:
:
:
:
:
:
:

PRIMARY ASSESMENT
A. AIRWAY (JALAN NAFAS)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

B. BREATHING (NAFAS)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

C. CIRCULATION (SIRKULASI)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

D. DISABILITY : AVPU
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

E. EXPOSURE

TEMUAN

ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

SECONDARY ASSESMENT
1. Keadaan umum:

2. History:
a) S (Signs & Symptom): .

.
b) A (Allergies): ..
.
c) M (Medication): ..

d) P (Past Medical History):

.
e) L (Last Meal, Last Menstrual):

.
f) E (Events): ..

3. Subjektif
Nyeri Dada: tidak terkaji
S : .
O : .
C : .
R : .

A
T
E
S

: .
: .
: .
: .

Nyeri Abdomen: tidak terkaji

P : .
Q : .
R : .
S : .
T : .

4. Objektif:
Observasi tanda-tanda vital dan SaO2
TTV :
BP
= mmHg
HR
= x/menit
RR
= x/menit
T
= 0C
SaO2
=

5. Pemeriksaan Head To Toe:

No.
1.

BAGIAN
Kepala

2.

Wajah

3.

Servikalis Dan
Leher

TEMUAN
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4.

Toraks

5.

Abdomen

6.

Pelvis

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7.

Ekstremitas

8.

Bagian
Punggung

9.

Neurologis

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PEMERIKSAAN PENUNJANG

1. Laboratorium
Pemeriksaan
HEMATOLOGI
Hemoglobin
Lekosit
Eritrosit
Hematokrit
Trombosit
RDW-CV

Hasil
.
..
.
..
.
..
.
..
.
..
.
..

MCV, MCH, MCHC

MCV
MCH
MCHC

.
..
.
..
.
..
.
..

Nilai Rujukan

Satuan

Metoda

14,00 - 16,00
4,0 - 10,5
3,90 5,50
37,00 47,00
150 450
11,5 14,7

gr/dL
ribu/uL
juta/uL
vol %
ribu/uL
%

Colorimetric
Impedance
Impedance
Analyzer Calculates
Impedance
Analyzer Calculates

80,0-97,0
27,0-32,0
32,0-38,0

fl
pg
%

Analyzer Calculates
Analyzer Calculates
Analyzer Calculates

HITUNG JENIS
Gran %
Limfosit %
MID %
Gran #
Limfosit #
MID #

KIMIA
Glukosa darah puasa
Hati
SGOT
SGPT
Ginjal
Ureum
Kreatinin
Elektrolit
Natrium
Kalium
Clorida

.
..
.
..
.
..
.
..
.
..
.
.
.
...
.
..
.
..
.
..
.
..
.
..
.
..
.
..

50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0

%
%
%
ribu/ uL
ribu/ uL
ribu/ uL

Impedance
Impedance
Impedance
Impedance
Impedance
Impedance

<200

mg/ dL

GOD-PAP

0-46
0-45

u /l
u/l

IFFC
IFFC

10-50
0.6-1.2
135-146
3,4-5,4
95-100

mg/dl
mg/dl
mmol/l
mmol/l
mmol/l

Modif-berhelot
Jaffe
ISE
ISE
ISE

.
..
.
..
.
..
.
..
.
..
2.

Foto
Hasil foto thorax (rontgen) :
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CTR= a + b x 100% =
C

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Hasil CT Scan :
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Kesimpulan:

3. EKG :

Interpretasi EKG :