ASUHAN KEPERAWATAN GAWAT DARURAT

ICU/ICCU
Nama Mahasiswa :__________________________
NIM :__________________________
Ruangan :__________________________

Tanggal masuk : Jam :

Tanggal pengkajian : Jam :
Ruang : No. Reg :
Pengkajian

I. IDENTITAS KLIEN
Nama : ______________
Usia : ______________ Penanggung jawab
Jenis Kelamin : ______________ Nama :_______________
Pendidikan : ______________ Usia :_______________
Pekerjaan : ______________ Agama : _______________
Agama : ______________ Pendidikan : _______________
Dx. Medis : _______________ Pekerjaan : _______________
No RM : _______________ Alamat : _______________
Alamat : ______________ Suku/bangsa : _______________
Suku/ bangsa : ______________

II. PENGKAJIAN PRIMER (Primary Survey)

Air Way

Breathing

Circulation

Disability
III. PENGKAJIAN SEKUNDER (Secondary Survey)
A. WAWANCARA
1. Keluhan utama:
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Riwayat penyakit sekarang:

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Riwayat penyakit dahulu:
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Riwayat penyakit keluarga:

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Riwayat Pekerjaan:
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Riwayat Geografi:
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Riwayat alergi:
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Kebiasaan sosial:
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Kebiasaan merokok:
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B. PEMERIKSAAN FISIK
Keadaan umum: ____________________________________________________
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1) Kepala dan Leher

Kepala
Mata
Hidung
Mulut
Telinga
Leher

2) Dada
Paru
Inspeksi
Palpasi
Perkusi
Auskultasi

Jantung
Inspeksi
Palpasi
Perkusi
Auskultasi

3) Abdomen
Paru
Inspeksi
Auskultasi
Palpasi
Perkusi

4) Ekstremitas
Ekstremitas atas
Kanan Kiri
Tanggal/jam(WIB)
Kesemutan Edema Nyeri Kesemutan Edema Nyeri

Gerak :
Tonus :
 Ekstremitas bawah
Kanan Kiri
Tanggal/jam(WIB)
Kesemutan Edema Nyeri Kesemutan Edema Nyeri

Gerak :
Tonus :

5) Genetalia

6) Sistem integumen
Tanggal/jam Warna kulit Turgor Mukosa bibir Capillary Kelainan
refil

7) Sistem persyarafan
Tanggal ..../..../2016 (jam)
Status mental
 Tingkat kesadaran
 GCS
 Gaya Bicara
Fungsi Intelektual
 Orientasi waktu
 Orientasi tempat
 Orientasi orang
Daya pikir
 Spontan, alamiah, masuk akal
 Kesulitan berpikir
 Halusinasi
Status emosional
 Alamiah dan datar
 Peramah
 Cemas
 Apatis

8) Aktivitas dan latihan

Bathing Dressing Toileting Transfering Continence Feeding KATZ

Keterangan : T = tergantung
 9) Nutrisi dan cairan

10) Pola eliminasi

11) Kenyamanan
Klien mengatakan merasa tidak nyaman yang disebabkan oleh nyeri yang
dirasakan. Hasil pengkajian nyeri:
Provocative/palliative :
Quality :
Region :
Saverity :
Time :

IV. PEMERIKSAAN PENUNJANG

1. Pemeriksaan Laboratorium
Tanggal :
Pemeriksaan Hasil Satuan Nilai Normal Keterangan
2. Pemeriksaan Diagnostik
A. Rontgen thoraks
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B. EKG
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C. AGD
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D. Lain-lain
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3. TERAPI OBAT
Nama Obat Fungsi Dosis Jalur Masuk
 1. ANALISA DATA
DATA MASALAH ETIOLOGI

2. PRIORITAS DIAGNOSA KEPERAWATAN

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 3. RENCANA KEPERAWATAN
No.Dx Tujuan Intervensi Rasional

Indicator Awal Tujuan

No.Dx Tujuan Intervensi Rasional

Indicator Awal Tujuan

4. IMPLEMENTASI
Tgl/Jam No. Dx Implementasi Respon Paraf
Tgl/Jam No. Dx Implementasi Respon Paraf
5. EVALUASI

Tgl/Jam No. Dx Evaluasi (SOAP) Paraf

S:

O:

A:
Indicator Skala awal Skala tujuan Skala akhir

P:
Tgl/Jam No. Dx Evaluasi (SOAP) Paraf

S:

O:

A:
Indicator Skala awal Skala tujuan Skala akhir

P: