FORMAT PENGKAJIAN

KEPERAWATAN GAWAT DARURAT

PSIK STIKes HANG TUAH

A. INFORMASI UMUM
Nama : Umur :
Tanggal lahir : Jenis kelamin :
Suku bangsa : Tanggal masuk:
Tanggal pengkajian : Dari/ rujukan :
Diagnosa Medik : ............................................................................................................
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Pengkajian primer
Airway (A)
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Breathing (B)
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Circulation (C)
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Disability (D)
GCS : E: M: V:
Kesadaran :
Kekuatan otot :
Pupil :
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Exposure (E)
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Foley Cateter(F)
Hari/ tanggal pemasangan :
Lama pemakaian :
Ukuran :

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Gastric Tube (G)

Hari/ tanggal pemasangan :

Lama pemakaian :
Ukuran :

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 Heart Monitor

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B. KELUHAN UTAMA

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C. RIWAYAT KESEHATAN SEBELUMNYA
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D. RIWAYAT KESEHATAN KELUARGA

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E. PEMERIKSAAN FISIK
F. AKTIVITAS, ISTIRAHAT DAN KENYAMANAN

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G. NUTRISI, CAIRAN DAN ELIMINASI

1. Intake Oral/ Enteral
a. Makan : ml/hari
b. Minum: ml/hari
2. Parenteral :
3. Eliminasi :
a. Urin : ml/hari
b. BAB : ml/hari

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H. Hasil pemeriksan laboratorium dan diagnostik

1. Hasil labor
2. Hasil Radiologi (CT-scan, X-Ray, MRI, USG,Echocardiografi)

3. Hasil EKG terbaru

 Medikasi/ Obat-Obatan Yang Diberikan Saat Ini
Rute Pemberian Obat
No Dosis Indikasi Kontra Indikasi
(Nama Obat)
 FORMAT ANALISA DATA
NO DATA PENUNJANG ETIOLOGI MASALAH
KEPERAWATAN
I. DIAGNOSA KEPERAWATAN
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Pekanbaru .............................
Mahasiswa

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 FORMAT RENCANA ASUHAN KEPERAWATAN

Nama klien : Nama mahasiswa :

Ruang : NIM :

No M. R :

NO Diagnosa Keperawatan Tujuan/ Sasaran Intervensi Rasional

 CATATAN PERKEMBANGAN

hari/ Tanda tangan

Diagnosa Keperawatan SOAP
tanggal perawat