Sekolah Tinggi Ilmu Kesehatan

BINA USADA BALI

SK. Mendiknas RI. Nomer 122/D/O/2007
Jalan Kubu Gunung Tegal Jaya Dalung - Badung Telp/Fax. (0361) 433132

PENGKAJIAN KEPERAWATAN GAWAT DARURAT DI RUANG IGD

Tgl/ jam: ………………………………… No. RM : ……………………………..

Triage : P1/P2/P3 Diagnosis Medis: ……………………………..
Transportasi : ambulan/mobil pribadi/lain-lain:…………………………...........................................
Nama : ........................................................ Jenis Kelamin : .................................................
Umur : ........................................................ Alamat : ............................................................
IDENTITAS

Agama : ...................................................... Status Perkawinan : ..........................................

Pendidikan : ............................................... Sumber Informasi : ...........................................
Pekerjaan : .................................................. Hubungan : .......................................................
Suku / bangsa : ........................................... Keluhan Utama : ..............................................

Jalan nafas :  Paten  Tidak Paten

Obstruksi :  Lidah  Cairan  Benda Asing  Tidak ada
 Muntahan  Darah  Oedema
Suara nafas :    Stridor  Tidak ada
AIRWAY

Snoring Gurgling
Keluhan lain : ............................................................................................................................
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Masalah keperawatan : ...............................................................................................................
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 Nafas  Spontan  Tidak Spontan

 Gerakan dinding dada  Simetris  Asimetris
 Irama nafas  Cepat  Dangkal  Normal  Ada
 Pola nafas  Teratur  Tidak Teratur
 Jenis  Dispneu  Kusmaul  Cyene Stoke  Lain
  Vesikuler   Wheezing  Ronchi
BREATHNG

Suara nafas Stridor

 Cuping hidung  Ada  Tidak ada
 Retraksi otot bantu nafas  Ada  Tidak ada
 Pernafasan  Dada  Perut RR: .........x/mnt

Keluhan lain : ............................................................................................................................

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Masalah keperawatan : ...............................................................................................................
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  Nadi  Teraba  Tidak Teraba N:
 Tekanan Darah ...................mmHg .........x/mnt
 Pucat  Ya  Tidak 
 Sianosis  Ya  Tidak 
 CRT  < 2 dtk  > 2 dtk 
 Akral  Hangat  Dingin
CIRCULATION

 Perdarahan  Ada  Tidak ada

 Lokasi .................................. 
 Jumlah ..........cc 
 Turgor  Elastis  Lambat 
 Diaphoresis  Ya  Tidak
 Riwayat kehilangan cairan berlebih  Diare  Muntah
 Luka Bakar
Keluhan lain : ............................................................................................................................
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Masalah keperawatan : ...............................................................................................................
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 Kesadaran  Composmentis  Delirium  Somnolen  Apatis  Koma
 GCS  Eye  Verbal  Motorik
 Pupil  Isokor  Unisokor  Pinpoint  Medriasis
 Refleks Cahaya  Ada  Tidak Ada
 Refleks Fisiologis  Patela (+/-) ...................
 Refleks Patologis  Babinzky (+/-) ...................
 Kernig (+/-) ...................
 Lain.................
 Kekuatan Otot

DISABILITY

Keluhan lain : ............................................................................................................................

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Masalah keperawatan : ...............................................................................................................
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  Deformitas  Ya  Tidak  Lokasi ...............................
 Contusio  Ya  Tidak  Lokasi ...............................
 Abrasi  Ya  Tidak  Lokasi ...............................
 Penetrasi  Ya  Tidak  Lokasi ...............................
EXPOSURE

 Laserasi  Ya  Tidak  Lokasi ...............................

 Edema  Ya  Tidak  Lokasi ...............................
 Luka Bakar  Ya  Tidak  Lokasi ...............................
 Jika terdapat Grade .............%  Lokasi ...............................
Luka/ vulnus,  Luas Luka ......................
kaji:  Warna Dasar Luka ......................
 Kedalaman Luka ......................

Keluhan lain : ............................................................................................................................

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Masalah keperawatan : ...............................................................................................................
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FIVE INTERVENTION Monitoring jantung :  sinus bradikardi  sinus takikardi
Saturasi oksigen : ............... %
Kateter urine :  ada  tidak ada
Pemasangan NGT :  Ada, warna cairan lambung : .................................
 Tidak

Hasil Laboratorium:
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Terapi Medis:
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Keluhan lain : ............................................................................................................................
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Masalah keperawatan : ...............................................................................................................
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 Nyeri :  Ada  Tidak Ada
Problem : .......................................................................................................................
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Qualitas/ quantitas : ...................................................................................................................
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Regio : .......................................................................................................................................
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Skala : ........................................................................................................................................
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Timing : .....................................................................................................................................
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Keluhan lain : ............................................................................................................................
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GIVE COMFORT

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Masalah keperawatan : ...............................................................................................................
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 Keluhan utama :
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Mekanisme cidera (trauma) :
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Sign / tanda gejala :
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Alergi :
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Medication / pengobatan :
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Post Medical History :
HISTORY

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Last Oral Intake:
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Event Leading Injury:
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 (fokus pemeriksaan pada daerah trauma / sesuai kasus nontrauma )
 Kepala dan wajah
Inspeksi :
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 Leher
Palpasi :
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Inspeksi :
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Palpasi :
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 Dada
Inspeksi :
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HEAD TO TOE

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Palpasi :
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Perkusi :
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Auskultasi :
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 Abdomen
Inspeksi :
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Auskultasi :
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Palpasi :
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Perkusi :
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 Pelvis dan perineum :
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 Ekstremitas :
 Atas:
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 Bawah
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Masalah keperawatan :
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Jejas :  Ada  Tidak

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Deformitas :  Ada  Tidak
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Tenderness :  Ada  Tidak
INSPECTION BACK/ POSTERIOR SURFACE

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Crepitasi :  Ada  Tidak
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Laserasi :  Ada  Tidak
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Keluhan lain : ............................................................................................................................
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Masalah keperawatan : ...............................................................................................................
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