Sekolah Tinggi Ilmu Kesehatan

BINA USADA BALI

SK MENDIKNAS RI. NOMOR 122/D/O/201
TERAKREDITASI BAN PT. NOMOR 351/SK/BAN- PT/Akred/PT/IV/2015
Komplek Kampus MAPINDO Jl. Padang Luwih, Tegal Jaya Dalung- Badung
Telp. (0361) 433132, Fax. 419959 Email: binausada@yahoo.com Web: binausadabali. ac.id

PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Tgl/ Jam : No. RM :

Triage : P1/P2/P3 Diagnosa Medis :
Transportasi : Ambulan/Mobil Pribadi/ Lain-lain........

IDENTITAS Nama :
Jenis Kelamin :
Umur :
Agama : Status Perkawinan :

Pendidikan :
Sumber Informasi :
Pekerjaan :
Suku /Bangsa : Hubungan :

Alamat : Keluhan Utama :

AIRWAY Jalan Nafas : Paten Tidak Paten

Obstruksi : Lidah Cairan Benda Asing Tidak Ada
Muntahan Darah Oedema
Suara Nafas : Snoring Guurgling Stridor Tidak Ada
Keluhan :

Masalah Keperawatan:

BREATHING Nafas : Spontan Tidak Spontan

Gerakan dinding dada : Simetris Asimetris

Irama Nafas : Cepat Dangkal Normal

 Pola Nafas : Teratur Tidak Teratur

Jenis : Dispnoe Kusmaul Cyne Stroke

Lain

Suara Nafas : Vesikuler Stidor Wheezing

Ronchi
Sesak Nafas : Ada Tidak Ada
Cuping hidung : Ada Tidak Ada
Retraksi otot buntu nafas : Ada Tidak Ada
Pernafasan : Pernafasan Dada Pernafasan Perut
RR : x/menit
Keluhan lain :

Masalah Keperawatan :

CIRCULATION Nadi : Teraba Tidak Teraba N:.........x/menit

BP:..........mmHg
Pucat : Ya Tidak Sianosis : Ya Tidak
CRT : <2 detik >2 detik
Akral : Hangat Dingin S:................0C
Pendarahan : Ya, Lokasi..................... Jumlah................cc Tidak
Tugor : Elastis Lambat, Diaphoresis: Ya Tidak
Riwayat kehilangan cairan berlebih : Diare Muntah Luka Bakar
Keluhan lain :

Masalah Keperawatan :

DISABILITY Kesadaran : Composmentis Delirium Samnolen Apatis

Koma
GCS : Eye..... Verbal..... Motorik......
Pupil : Isokor Unisokor pinpoint Medriasis
Refleks Cahaya : Ada Tidak Ada
Reflek Fisiologis : Patela (+/-) Lain-lain..........................
Reflek Patologis : Babinzky(+/-) Kerning(+/-) Lain-
 lain..................
Kekuatan Otot :

Keluhan lain :

Masalah Keperawatan:

EXPOSURE

Deformitas : Ya Tidak Lokasi..........

Contusio : Ya Tidak Lokasi..........
Abrasi : Ya Tidak Lokasi..........
Penetras : Ya Tidak Lokasi..........
Leserasi : Ya Tidak Lokasi..........
Edema : Ya Tidak Lokasi..........
Luka bakar : Ya Tidak Lokasi..........
Grade :.............%
Jika ada luka / vulnus, kaji :
Luas Luka :
Warna dasar luka :
Kedalaman :
Lain-lain :
 Masalah Keperawatan:
FIVE Monitoring Jantung : Sinus Bradikardi Sinus Takikardi
INTERVENSI Saturasi O2 :..........%
Kateter Urine : Ada Tidak
Pemasangan NGT : Ada, warna Lambung:.......... Tidak

Hasil Laboratorium :

Terapi Medis :

Lain-lain

Masalah Keperawatan :

GIVE Nyeri :
COMFORT Problem :
Qualitas/Quantitas :
 Region :
Skala :
Timing :
Lain-lain :

Masalah Keperawatan:

HISTORY Keluhan Utama :

Mekanisme Cedera (Trauma) :

Sign/Tanda Gejala :

Medication/Pengobatan :

Past Medical History/Riwayat Penyakit sebelumnya :

 Last Oral Intake/Makan terakhir :

Even leading injury/Peristiwa sebelum/awal cedera:

HEAD TO (Fokus pemeriksaan pada daerah trauma/ sesuai kasus non trauma)
TOE

Kepala dan Wajah :

Leher :

Dada :
Abdomen dan Pinggang :

Pelvis dan Perineum :

Ekstremitas :

Masalah Keperawatan:

Jejas : Ada Tidak

Deformitas : Ada Tidak
Tenderness : Ada Tidak
Crepitasi : Ada Tidak
Laserasi : Ada Tidak
Lain-lain : Ada Tidak

Masalah Keperawatan :
DIAGNOSA KEPERAWATAN
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