PENGKAJIAN KEPERAWATAN KEGAWATDARURATAN

Nama Mahasiswa : Tanggal Pengkajian :

NIM : Ruang :

Pengkajian dilakukan pada hari : jam :

I. IDENTITAS
1. Nama pasien :
2. Pekerjaan :
3. Umur :
4. Pendidikan :
5. Alamat :
6. No. Telp :
7. Status perkawinan: kawin/ janda/ duda/ belum kawin
8. Agama :
9. Cara masuk :

II. PENGKAJIAN PRIMER

1. Airway
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2. Breathing
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3. Sirkulasi
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4. Disability
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5. Exposure
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III. PENGKAJIAN SEKUNDER
A. Riwayat Kesehatan
1. Data diperoleh dari: pasien orang lain
2. Keluhan utama
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3. Riwayat keperawatan sekarang
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4. Riwayat keperawatan dahulu

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5. Riwayat penyakit keluarga
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6. Triage
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B. Pengkajian Fisik
1. Sistem pernafasan
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2. Sistem kardiovaskuler
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3. Sistem persarafan

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4. Sistem pengindraan

a. Penglihatan

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b. Penciuman

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c. Pendengaran

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5. Sistem perkemihan

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6. Sistem pencernaan

a. Mulut

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b. Abdominal

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c. Bowel

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7. Sistem muskuloskeletal

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8. Sistem integumen

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9. Sistem reproduksi

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10. Sistem endokrin

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C. Pemeriksaan penunjang

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D. Program terapi
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DAFTAR MASALAH

Tanggal
No Tanggal/jam Data fokus Dx keperawatan TTD
teratasi
 RENCANA KEPERAWATAN

Tgl/jam No Dx Keperawatan Tujuan Intervensi TTD

 TINDAKAN KEPERAWATAN

Dx
Tgl/jam Tindakan keperawatan Respon TTD
Keperawatan
 EVALUASI KEPERAWATAN

Tgl/Jam Dx Keperawatan Catatan Perkembangan TTD