PEMERINTAH KABUPATEN KUPANG

RUMAH SAKIT UMUM DAERAH NAIBONAT

JL. TIMOR RAYA, KM 37-OELAMASI
Kecamatan Kupang Timur, Kab. Kupang, Tlp. 0380-85362
Email : rsnaibonat@yahoo.co.id

No. RM :…………………..
PENGKAJIAN IGD
Nama : .....................................................
Tgl lahir/umur :..................... /.........../ L / P
Alamat : ………………..…..……………….
Cara datang Transportasi ke IGD Komunikasi

Kejadian Tgl : ................................... Jam....................... Di ……………………………………

Datang di IGD Tgl :…………………… Jam ………………..
Keadaan Pra-Hospital (Vital Sign)
GCS : ................................... Tensi : ............ / ........... mmHg Nadi : ............ X / mnt
RR : ..........................X / mnt Suhu : ............ oC
Pra-Hospital
 CPR  O2  Infus  NGT  ETT  BVM  Bebat  Bidai  Jahit  Tracheostomy  Suction
 Pipa Oro / Nasopharingeal  Urine Kateter  Lain : ...........................................................................
 Obat-obatan : ...........................................................................................................................................................
TRIAGE : Jam …… Oleh Perawat : . t Axila : ………. oC Nadi : ………… x / mnt
……………… t Rectal: ………. oC RR : ………… x / mnt
Subjektif (Keluhan Utama) : BB : ………... kg Tensi : ……... / ……. mmHg
…………………………………………………… Skala Nyeri
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…………………………………………………… Skrining Resiko Cedera / Jatuh
Riwayat Penyakit Dahulu  Ya  Tidak
 HT  DM  PJK  Asthma  Tidak ada Kategori Triage
 Lainnya, …………………………………………  P1  P2  P3  P0 / DOA
Allergi :  Tidak  Ya ……………………………………………………………………………………
Objektif (Keadaan Umum)  Baik  Sedang  Buruk
Airways (A) Breathing (B) Circulation (C) Disability (D)
 Patent  Gerakan dada  Nadi carotis : + / -  Eye : …………..
 Partial Obsturktif  Simetris  Nadi radialis : + / -  Verbal : ………….
 Total Obstruktif  Asimetris  CRT : < 2 dtk / > 2 dtk  Motorik : ………….
 Stridor Total : …………..
 Jenis Kulit / Mukosa
 Normal  Jaundice
 Retraktif  Diaforesis
 Kusmaul  Cyanosis
 Dangkal  Pucat
 Tackypnoe  Normal
Status Psikologis
 Cemas  Depresi  Khawatir  Marah  Takut
 Gelisah  Tidak ada  Lain-lain ………………………………………………………

Subjektif (Anamnesa) : Periksa Dokter Jam : ………… WIB

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Objektif (Pemeriksaan Fisik) :
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Pemeriksaan Penunjang : (EKG / Laborat / Rontgen / CT Scan / Lainnya)
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Asessment (Diagnosa Kerja)
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Planning (Terapi / Tindakan / Konsul) :
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Keluar dari IGD Jam : ……….. WIB
Status Medik
 Gawat Darurat  Darurat Tidak Gawat
 Gawat Tidak Darurat  Tidak Gawat Tidak Darurat
Rencana Tindak Lanjut
 KRS  MRS  Pulang Paksa  D.O.A
 Pindah ke ……………………………………….  Lain-lain …………………………………………..
 Derajat transfer : 0 1 2 3
Diagnosa Utama / ICD – X : ……………………………………………………………………………..

Perawat IGD Dokter IGD

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