ASUHAN KEPERAWATAN KRITIS/EMERGENCY

PADA Tn/NyDENGAN..DISERTAI
DI RUANG IGD RSUD ..
A. PENGKAJIAN
Tanggal Masuk
Tanggal Pengkajian

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

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Identitas Penanggung Jawab

Nama
: .................................................
Umur
: .................................................
Jenis Kelamin
: .................................................
Alamat
: .................................................
Hub. Dengan Klien : .................................................
a. PRIMARY SURVEY
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 whezzing
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

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
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
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Nadi
: .........................................
RR
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Suhu
: .........................................
Anamnesa
Riwayat penyakit sekarang
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
Pemeriksaan

Hasil

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