FORMAT PENGKAJIAN KEGAWATDARURATAN

A. IDENTITAS KLIEN
Nama : ..............................................................................................
Jenis Kelamin : ..............................................................................................
Umur : ..............................................................................................
Pekerjaan : ..............................................................................................
Suku :...............................................................................................
Agama : ..............................................................................................
Pendidikan Terakhir : ..............................................................................................
Alamat : ..............................................................................................
No. registrasi : ..............................................................................................
Tgl. MRS : ..............................................................................................
Tgl. pengkajian : ..............................................................................................
Diagnosa medis : ..............................................................................................

B. RIWAYAT KEPERAWATAN
1. Keluhan utama / alasan masuk rumah sakit
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2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu
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4. Riwayat Kesehatan Keluarga
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C. PENGKAJIAN PERSISTEM
Keadaan umum :
TTV : N : x/menit RR : x/menit

TD : mmHg S : C

Akademi Keperawatan Pemerintah Kota Pasuruan 1

 Breath (B1)
1. Pergerakan Dada :
o Simetris
o Tidak simetris
2. Pemakaian otot bantu nafas
o Ada, jenis :
o Tidak ada
3. Batuk
o Produktif
o Tidak produktif
4. Sputum
o Coklat
o Kental
o Berdarah
o encer
5. Alat bantu nafas
o Tidak ada
o Ada, jenis :
6. Lain-lain :

Blood (B2)
1. Suara jantung (S1 S2 S3 S4)
o Tunggal
o Gallop
o Murmur
2. Irama jantung
o Reguler
o Irreguler
3. CRT
o < 2 detik
o > 2detik
4. JVP
o Normal
o Meningkat
5. CVP
o Ada
o Tidak ada
Nilai :
6. Edema
o Ada
o Tidak ada
Tempat :
7. Lain-lain :

Brain (B3)
1. Tingkat Kesadaran
o Kualitatif
o Kuantitatif (GCS)

Akademi Keperawatan Pemerintah Kota Pasuruan 2

 E...........V...........M..........
2. Reaksi pupil
a) Kanan :
o Ada, diameter
o Tidak ada
b) Kiri :
o Ada, diameter
o Tidak ada
3. Refleks fisiologis
o Ada
o Tidak ada
4. Refleks patologis
o Brudzinki
o Brudzinki
5. Meningeal sign
o Ada
o Tidak ada
6. Lain-lain :

Bladder (B4)
1. Urin
o Jumlah
o Warna
2. Kateter
o Ada, hari ke...
o Jenis...
o Tidak ada
3. Kesulitan BAK
o Ya
o Tidak
4. Lain-lain :

Bowel (B5)
1. Mukosa bibir
o Kering
o Lembab
2. Lidah
o Kotor
o Bersih
3. Keadaan gigi
o Lengkap
o Gigi palsu
4. Nyeri telan
o Ya
o Tidak
5. Abdomen

Akademi Keperawatan Pemerintah Kota Pasuruan 3

 o Distensi
o Tidak distensi
6. Peristaltic usus
o Normal
o Menurun
o Meningkat
o Nilai :
7. Mual
o Ya
o Tidak
8. Muntah
o Ya
o Tidak
o Jumlah/frekuensi :
9. Hematemesis
o Ya
o Tidak
o Jumlah/frekuensi :
10. Melena
o Ya
o Tidak
11. Terpasang NGT
o Ya
o Tidak
12. Diare
o Ya
o Tidak
o Jumlah/frekuensi :
13. Konstipasi
o Ya
o Tidak
o Sejak
14. Asites
o Ya
o Tidak
15. Lain-lain :

Bone (B6)
1. Turgor
o Baik
o Jelek
2. Perdarahan kulit
o Ada
o Tidak ada
o Jenis
3. Icterus
o Ya
o Tidak ada

Akademi Keperawatan Pemerintah Kota Pasuruan 4

 4. Akral
o Hangat
o Kering
o Merah
o Dingin
o Pucat
o Basah
5. Pergerakan sendi
o Bebas
o Terbatas
o Skala
6. Fraktur
o Ada
o Tidak ada
o Jenis
o Lokasi
7. Luka
o Ada
o Tidak ada
o Jenis
o Lokasi
8. Lain-lain :

D. PEMERIKSAAN PENUNJANG
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E. LAIN-LAIN
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F. TERAPI
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Perawat

Akademi Keperawatan Pemerintah Kota Pasuruan 5

NIM.