FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT

A. PENGKAJIAN

No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...

Nama : Jenis Kelamin : L/P Umur :

IDENTITAS

Agama : Status Perkawinan : Pendidikan :

Pekerjaan : Sumber informasi : Alamat :

Diagnosa Medis :

TRIAGE Merah Kuning Hijau Hitam

GENERAL IMPRESSION

Keluhan Utama :

Mekanisme Cedera :
PRIMARY SURVEY

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...

AIRWAY

Jalan Nafas :  Paten  Tidak Paten

Obstruksi :  Lidah  Cairan  Benda Asing

Suara Nafas : Snoring Gurgling Stridor N/A

Keluhan Lain: ... ...

BREATHING
 Gerakan dada :  Simetris  Asimetris

Irama Nafas :  Cepat  Dangkal  Normal

Pola Nafas :  Teratur  Tidak Teratur

Retraksi otot dada :  Ada  Tidak ada

Sesak Nafas :  Ada  Tidak ada

Frekuensi Nafas : ....................

Keluhan Lain : ....................

CIRCULATION

Nadi :  Teraba  Tidak teraba

Jumlah : x/menit

Sianosis :  Ya  Tidak

CRT :  < 2 detik  > 2 detik

Perdarahan :  Ya  Tidak ada Jumlah : .............. CC

Keluhan Lain: ....................

DISABILITY

Respon : Alert  Verbal  Pain  Unrespon

Kesadaran :  CM  Delirium  Somnolen  ... ...

PRIMARY SURVEY

GCS :  Eye ...  Verbal ...  Motorik ...

Jumlah GCS :

Pupil :  Isokor  Unisokor  Pinpoint  Medriasis

Refleks Cahaya:  Ada  Tidak Ada

 Lateralisasi :  Ada  Tidak Ada

Keluhan Lain : … …

EXPOSURE
Deformitas :  Ya  Tidak

Contusio :  Ya  Tidak

Abrasi :  Ya  Tidak

Penetrasi :  Ya  Tidak

Burn :  Ya  Tidak

Laserasi :  Ya  Tidak

Swelling :  Ya  Tidak

Keluhan Lain: ....................

ANAMNESA
SECONDARY SURVEY

Riwayat Penyakit Saat Ini : ....................

Riwayat Penyakit Sebelumnya : ....................

Sign and Symptom :

Alergi :
 Medikasi :

Past Medical History :

Last Meal/ Makan Minum Terakhir :

Event/ Peristiwa Penyebab :

Tanda-tanda Vital :

BP : mm/Hg N: x/menit S: RR : x/menit

Keluhan Nyeri (PQRST)

PEMERIKSAAN FISIK

Kepala dan Leher:

Inspeksi ... ...

Palpasi ... ...

Dada:

Inspeksi ... ...

Palpasi ... ...

SURVEY

Perkusi ... ...

Auskultasi ... ...

Abdomen:

Inspeksi ... ...

Palpasi ... ...

Perkusi ... ...

Auskultasi ... ...

Pelvis:

Inspeksi ... ...

Palpasi ... ...

Ektremitas Atas/Bawah:

Inspeksi ... ...

Palpasi ... ...

Punggung :

Inspeksi ... ...

Palpasi ... ...

Neurologis :

PEMERIKSAAN PENUNJANG
1. Pemerikasaan Lab

2. Pemeriksaan Diagnostik
  RONTGEN  CT-SCAN  USG  EKG

 ENDOSKOPI  Lain-lain, ... ...

Hasil :

Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :

Keterangan :
NAMA TERANG :

B. ANALISA DATA
NO DATA MASALAH
KEPERAWATAN
DS DO

C. DIAGNOSA KEPERAWATAN

D. RENCANA KEPERAWATAN
NO DIAGNOSA TUJUAN INTERVENSI RASIONAL
 KEPERAWATAN

E. TINDAKAN KEPERAWATAN
NO DIAGNOSA KEPERAWATAN TINDAKAN EVALUASI

F. EVALUASI KEPERAWATAN
NO DIAGNOSA KEPERAWATAN EVALUASI

Panduan Pengumpulan Data

 PROGRAM ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN BALI

KEPERAWATAN GAWAT DARURAT

UNIT RAWAT INTENSIVE

Nama Mahasiswa :

NIM :

PENGKAJIAN Nama : ………….............................................................. Penanggung jawab :………………………

KEPERAWATAN
Umur : …………………. Thn Jenis Kelamin : L/ P Umur : …………..Thn

Agama : Hindu Islam Kristen Budha ………. Jenis Kelamin : L / P

Pendidikan : ………………… Pekerjaan : …………… Alamat : ………………………………….....

Alamat : …………………………………………….. ………………………………………………

…………………………………………….. ………………………………………………

Perkawinan : Kawin / Belum Kawin / Lain-lain Telp : ……………………………………….

Jam : ………………………………………..

Keluhan Utama MRS:

Keluhan Utama saat pengkajian:

Riwayat penyakit saat ini :

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Riwayat alergi :

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Riwayat pengobatan :

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Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga :

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PENGKAJIAN DIAGNOSA TINDAKAN

KEPERAWATAN KEPERAWATAN KEPERAWATAN

BREATHING

Airways

Snoring Stridor/crowing

Gurgling Tidak ada

Wheezing Tanda Fraktur Cervikal (ada/tidak ada)

Lain-lain (………………………………………)

Breating (Pola Nafas)

Laju Pernafasan

Dispnea Tachipneu Bradipneu

Orthponeu Apneu Lain-lain (………………)

RR : …..

Irama Pernafasan

Teratur Tak TeraturLain-lain (………………)

PengembanganParu
 Simetris Asimetris Lain-lain (………………)

Flail Chest

Bising pernafasan (auskultasi)

Tidak ada Vesikular Lain-lain (………………)

Perkusi pernafasan

Sonor Hipersonor Pekak

Lain-lain (………………)

Penggunaan ototBantu napas

Bahu diangkat Retraksi dada M. Sternocleidomastoideus

Cuping Hidung Pernafasan perut Lain-lain (………………)

Oksigenasi

Akral dingin Pucat Sianosis

Lain-lain
(……………………….....................................................................................................
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BLOOD

Perdarahan

Lokasi : …

Jumlah :…
Pulsasi

Kuat Lemah Tidak teraba

Laju nadi

Takikardia Bradikardia Normal

Ket : …. x/mnt

Tekanan darah

Hipotensi Hipertensi Tidak terukur

Normal

TD : … mmHg

Nyeri dada

Ada Tidak ada

Lokasi :…

Karakteristik : …

Jumlah :…

Perfusi

Akral dingin Pusing/nyeri kepala Kesemutan

Tremor Pucat Edema

Pengisian kapiler < 3 detik > 3 detik

Produksi Urine

AnuriaOliguria
 Normal

Urine output : … CC/jam

BRAIN

Kesadaran

Compos mentis Samnolen Koma

Delirium Apatis

GCS

Eye .... Verbal ... Motorik …

PupilIsokor Anisokor Medriasis

Pinpoint

Reflek Cahaya Ada Tidak ada

Reflek Fisiologis Patella Lain-lain ...

Reflek Patologis Babinzky Kernig

Lain-lain ...

Bicara Koheren Inkoheren

Tidur Malam......jam/hari Siang....jam/hari

Ansietas Ada Tidak ada

Lain-lain : (............................................................................................................)

BLADDER

Nyeri pinggang Ada Tidak ada

BAK Lancar Inkontenensia

Anuri

Nyeri BAK Ada Tidak ada

Frekuensi BAK.... warna...Darah Ada Tidak ada

Kateter Ada Tidak ada

Jumlah urine output.... CC/....jam

BOWEL

TB : ... CM BB: ... Kg

Nafsu makan Baik Menurun

Keluhan Mual Muntah

Sulit menelan

Makan : Frekuensi... x/hari Jumlah :... porsi

Minum : Jumlah ... cc/24 jam

Meteorismus Ada Tidak ada

Acites Ada Tidak ada

BAB Teratur Tidak teratur

Frekuensi BAB : ... x/hari Konsistensi... Warna : darah/lendir

BU (peristaltik usus) .... x/mnt

Lain-lain ...

BONE

Nyeri Ada Tidak ada

Problem : ...

Regio : ...

Timing : ...

Kekuatan otot : ...

Kualitas/kuantitas : ...

Skala : ...

Deformitas Ada Tidak ada Lokasi...

Contusio Ada Tidak ada Lokasi...

Abrasi Ada Tidak ada Lokasi...

Penetrasi Ada Tidak ada Lokasi...

Laserasi Ada Tidak ada Lokasi...

Edema Ada Tidak ada Lokasi...

Luka bakar Ada Tidak ada Lokasi...

Grade : ... %

Jika ada luka/vulnus, kaji :

Luas luka : ...

Warna dasar luka :...

Kedalaman : ...

Aktivas dan latihan : 0 1 2 3 4

Makan/minum : 0 1 2 3 4

Mandi : 0 1 2 3 4

Toileting : 0 1 2 3 4
Berpakaian : 0 1 2 3 4

Mobilisasi : 0 1 2 3 4

Berpindah : 0 1 2 3 4

Ambulasi : 0 1 2 3 4

Lain-lain : ....

Keterangan :

0 : Mandiri

1 : Alat bantu

2 : Dibantu orang lain

3 : Dibantu orang lain dan alat

4 : Tergantung total

Keracunan (intoksikasi)

Makanan Gigitan binatang Zat kimia

Gas Obat – obatan Lain-lain (………………)

Pengkajian Sekunder

Riwayat Kesehatan Sekarang :

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Riwayat Kesehatan Lalu :

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Riwayat Kesehatan Keluarga :

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Pengkajian Head to Toe

Kepala dan wajah

Leher

Thorak

Abdomen dan pinggang

Pelvis dan Perineum

Ekstremitas

Integumen
 Pemeriksaan Penunjang & Terapi Medis

Radiologi Laboratorium Darah Pemeriksaan Lain Terapi Medis

Masalah Keperawatan :

1. ……………………………………………………….
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