FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT DI IGD

I. PENGKAJIAN

Nama Pengkaji :......................................................................................

Tanggal Pengkajian :......................................................................................

Jam Pengkajian :......................................................................................

A. Biodata pasien
Nama : ......................................................................................
Jenis kelamin : ......................................................................................
Pendidikan : ......................................................................................
Pekerjaan : ......................................................................................
Usia : ......................................................................................
Status Pernikahan : ......................................................................................
No. RM : ......................................................................................
Diagnosa Medis : ......................................................................................
Alamat : ......................................................................................

B. Biodata Penanggung Jawab

Nama : ......................................................................................
Jenis Kelamin : ......................................................................................
Pendidikan : ......................................................................................
Pekerjaan : ......................................................................................
Hubungan dengan klien: ....................................................................................
Alamat : ......................................................................................

C. Pengkajian Primer
1) Airway (Jalan nafas)
Sumbatan:
( ) benda asing
( ) darah
( ) bronkospasme
( ) sputum
( ) lendir
( ) Bebas/ tanpa sumbatan
 Suara nafas:
( ) Snoring
( ) Gurgling
( ) Stridor
Masalah Keperawatan : ......................................................................................
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2) Breathing (pernafasan)
Sesak, dengan
( ) aktivitas
( ) tanpa aktivitas
( ) menggunakan otot tambahan
Frekuensi :.........x/mnt
Irama : ( ) teratur ( ) tidak teratur
Kedalaman : ( ) dalam ( ) dangkal
Batuk : ( ) produktif ( ) non produktif
Sputum : ( ) ada ( ) tidak ada
Warna:......................
Konsistensi:..............
Bunyi nafas:
( ) ronchi
( ) wheezing
( ) crakles
( ) ...........................
Masalah Keperawatan : ......................................................................................
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3) Circulation (sirkulasi)
Sirkulasi perifer:
Nadi :......................x/mnt
Irama : ( ) teratur ( ) tidak teratur
Denyut : ( ) lemah ( ) kuat
TD :.......................mmHg
Ektremitas: ( ) hangat ( ) dingin
Warna Kulit: ( ) cyanosis ( ) pucat ( ) kemerahan
Nyeri dada: ( ) ada ( ) tidak ada
 Karakteristik nyeri dada:
( ) menetap
( ) menyebar
( ) seperti ditusuk tusuk
( ) seperti ditimpa benda berat
CRT : ( ) < 2 detik ( ) > 2 detik
Edema : ( ) iya ( ) tidak
Lokasi edema:
( ) muka
( ) tangan atas
( ) tungkai
( ) anasarka
Eliminasi dan cairan:
BAK:.....................x/ hari
Jumlah : ( ) sedikit ( ) banyak ( ) sedang
Warna : ( ) kuning jernih ( ) kuning kental ( ) putih
Rasa sakit : ( ) iya ( ) tidak
BAB:.......................x/ hari
Diare:
( ) iya
( ) tidak
( ) berdarah
( ) cair
( ) berlendir
Turgor : ( ) baik ( ) sedang ( ) buruk
Mukosa : ( ) lembab ( ) kering
Suhu:...........................0C
Masalah Keperawatan : ......................................................................................
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4) Dissability
Tingkat kesadaran:
( ) composmentis
( ) apatis
( ) somnolen
( ) stupor
( ) soporocoma
( ) koma
Pupil
( ) isokor
( ) anisokor
( ) miosis
( ) midriasis
Reaksi terhadap cahaya
Kanan
( ) positif
( ) negatif
Kiri
( ) positif
( ) negatif
GCS: Eye Verbal Motorik = E..........V...........M........... =......................

Terjadi :
( ) kejang
( ) pelo
( ) kelumpuhan/ kelemahan
( ) mulut mencong
( ) afasia
( ) disartria
( ) berlendir

Nilai kekuatan otot:

Refleks: ....................................................................................................................
Babisnky : .....................................................................................................
Patella: .......................................................................................................
 Bisep/ trisep: ................................................................................................
Brudynsky: ....................................................................................................
Masalah Keperawatan : ......................................................................................
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5) Eksposure
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Masalah Keperawatan : ......................................................................................

D. Pengkajian Sekunder
1) Keluhan utama (Bila nyeri, pengkajian PQRST) :
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2) Alergi terhadap obat, makanan tertentu :

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3) Medikasi/ pengobatan terakhir :

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4) Event of injury/ penyebab injury :
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5) Pengalaman pembedahan :
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6) Riwayat penyakit sekarang :

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7) Riwayat penyakit dahulu :

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8) Pemeriksaan Head to Toe

a. Kepala
Kesimetrisan wajah :..........................................................................................
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Rambut: warna, distribusi, tekstur, tengkorak/ kulit kepala :
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Sensori :..............................................................................................................
Mata : inspeksi bola mata, kelopak mata, konjungtiva, sklera, pupil, reaksi
pupil terhadap cahaya
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Telinga : letak, bentuk, serumen, kemampuan mendengar: uji berbisik
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Hidung : Deviasi septum nasi, kepatenan jalan nafas lewat hidung, discharge
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Mulut : bibir sumbing, mukosa mulut, tonsil, gigi, gusi, lidah, bau mulut
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b. Leher
Deviasi/ simetris, cidera cervikal
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kelenjar thyroid
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kelenjar limfe
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Trakea
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JVP
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c. Dada
I : Kesimetrisan, penggunaan otot bantu nafas, ictus cordis
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P : Taktil fremitus, ada/ tidaknya masa, ictus cordis teraba/ tidak

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P : Adanya cairan di paru, suara perkusi paru dan jantung
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A : Suara paru, jantung
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d. Abdomen
I : datar, cembung, cekung, lembek, elastik, asites, kembung
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A : Bising usus
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P : Posisi hepar, limpa, ginjal, kandung kemih, nyeri tekan
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 P : Suara abnormal
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e. Ekstremitas
Luka : ( ) iya ( ) tidak
Dalam : ( ) iya ( ) tidak
Perdarahan : ( ) iya ( ) tidak
Deformitas :
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Kontraktur :
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Nyeri :
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Krepitasi :
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f. Kulit/ Integumen
Mukosa : ( ) lembab ( ) kering
Kulit: ( ) bintik merah ( ) jejas ( ) lecet-lecet ( ) luka
 E. Pemeriksaan Penunjang

Nama : Tanggal :

PEMERIKSAAN HASIL NILAI NORMAL INTERPRETASI

HEMATOLOGI
Hemoglobin 14,0 – 18,0 g/dl
Eritrosit 4,0 – 10,5 ribu/µl
Leukosit 4,50 – 6,00 juta/µl
Hematokrit 42.00 – 52.00 vol%
Trombosit 150 – 450 ribu/µl
RDW-CV 11,5- 14,7 %
MCV, MCH, MCHC
MCV 80-97 Fl
MCH 27-32 Pg
MCHC 32-38 %
HITUNG JENIS
Basofil % 0,0-1,0 %
Eusinofil % 1,0-3,0 %
Gran % 50,0-70,0 %
Limfosit % 25,0-40,0 %
Monisit % 3,0-9,0 %
Basofil # < 1 ribu/µl
Eusinofil # < 3 ribu/µl
Gran # 2,50-7,00 ribu/µl
Limfosit # 1,25-4,0 ribu/µl
MID # 0,30-1.00 ribu/µl
PROTHROMBIN TIME
Hasil PT 9,9-13,5 detik
INR -
Control normal PT -
Hasil APTT 22,2-37,0 detik
Control normal APTT -
KIMIA
GULA DARAH
Gula darah sewaktu < 200 mg/dl
HATI
SGOT 0-46 U/l
SGPT 0-45 U/l
GINJAL
Ureum 10-50 mg/dl
Creatinin 0,7-14 mg/dl
ELEKTROLIT
Natrium 135-146 mmol/l
Kalium 3,4-5,4 mmol/l
Clorida 95-100 mmol/l
 F. Terapi Medis
Nama Obat,
Frekuensi
Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Pemberian, Dosis,
Cara Pemberian
 Nama Obat,
Frekuensi
Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Pemberian, Dosis,
Cara Pemberian
 ANALISA DATA
NO. DATA PROBLEM ETIOLOGI
NO. DATA PROBLEM ETIOLOGI
PRIORITAS MASALAH KEPERAWATAN :
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RENCANA ASUHAN KEPERAWATAN
Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
IMPLEMENTASI DAN EVALUASI
DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI PARAF EVALUASI
IMPLEMENTASI DAN EVALUASI
DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI PARAF EVALUASI