FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT PADA ORANG

DEWASA
IDENTITAS

No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...
Nama : Jenis Kelamin : L/P Umur :
Agama : Status Perkawinan : Pendidikan :
Pekerjaan : Sumber informasi : Alamat :

TRIAGE P1 P2 P3 P4
GENERAL IMPRESSION
Keluhan Utama :

Mekanisme Cedera :

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...
Diagnosa Keperawatan:
AIRWAY
Inefektif airway b/d … … …
Jalan Nafas :  Paten  Tidak Paten Kriteria Hasil : … … …
Obstruksi :  Lidah  Cairan  Benda Asing  N/A
PRIMERY SURVEY

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

Keluhan Lain: ... ...

Intervensi :
1. … …
2. … …

Diagnosa Keperawatan:
1. Inefektif pola nafas b/d … … …
BREATHING 2. Kerusakan pertukaran gas b/d … … …

Gerakan dada :  Simetris  Asimetris Kriteria Hasil : … … …

Irama Nafas :  Cepat  Dangkal  Normal
Pola Nafas :  Teratur  Tidak Teratur
Retraksi otot dada :  Ada  N/A
Sesak Nafas :  Ada  N/A  RR : ... ... x/mnt
Intervensi :
Keluhan Lain: … …

1
 Diagnosa Keperawatan:
1. Penurunan curah jantung b/d … … …
CIRCULATION 2. Inefektif perfusi jaringan b/d … … …
3.
Nadi :  Teraba  Tidak teraba Kriteria Hasil : … … …
Sianosis :  Ya  Tidak
CRT :  < 2 detik  > 2 detik
Pendarahan :  Ya  Tidak ada
Keluhan Lain: ... ...

Intervensi :
PRIMERY SURVEY

1. Lakukan CPR dan Defibrilasi

2. Kontrol perdarahan
3. ……
4. ……

Diagnosa Keperawatan:
1. Inefektif perfusi serebral b/d … … …
DISABILITY 2. Intoleransi aktivias b/d … … …
3. … … …

Respon : Alert  Verbal  Pain  Unrespon Kriteria Hasil : … … …

Kesadaran :  CM  Delirium  Somnolen  ... ... ...
GCS :  Eye ...  Verbal ...  Motorik ...
Pupil :  Isokor  Unisokor  Pinpoint  Medriasis
Refleks Cahaya:  Ada  Tidak Ada
Intervensi :
Keluhan Lain : … …
1. Berikan posisi head up 30 derajat
2. Periksa kesadaran dann GCS tiap 5 menit
3.
4.
5.
6.
7.
8.
9. … … …
 Diagnosa Keperawatan:
1. Kerusakan integritas jaringan b/d … …
EXPOSURE 2. Kerusakan mobilitas fisik b/d … …
3. … … …

Deformitas :  Ya  Tidak Kriteria Hasil : … … …

Contusio :  Ya  Tidak
Abrasi :  Ya  Tidak
Penetrasi : Ya  Tidak
Laserasi : Ya  Tidak
Edema : Ya  Tidak
Keluhan Lain:
……

Intervensi :
1.
2.
3.
4.
5.
6. Perawatan luka
7. Heacting
8. … …

Diagnosa Keperawatan:
1. Regimen terapiutik inefektif b/d … … …
ANAMNESA 2. Nyeri Akut b/d … … …
3. … … …

Riwayat Penyakit Saat Ini : … … … Kriteria Hasil : … … …

SECONDARY SURVEY

Alergi :

Medikasi :

Riwayat Penyakit Sebelumnya:

Intervensi :
1. … … …
Makan Minum Terakhir: 2. … … …

Even/Peristiwa Penyebab:

Tanda Vital :
BP : N: S: RR :
 Diagnosa Keperawatan:
1. … … …
PEMERIKSAAN FISIK 2. … … …

Kepala dan Leher: Kriteria Hasil : … … …

Inspeksi ... ...
Palpasi ... ...
Dada:
Inspeksi ... ...
Palpasi ... ...
Perkusi ... ...
Auskultasi ... ...
Abdomen:
Inspeksi ... ...
Palpasi ... ...
Perkusi ... ...
Intervensi :
Auskultasi ... ...
Pelvis:
SECONDARY SURVEY

Inspeksi ... ...

Palpasi ... ...
Ektremitas Atas/Bawah:
Inspeksi ... ...
Palpasi ... ...
Punggung :
Inspeksi ... ...
Palpasi ... ...
Neurologis :
Diagnosa Keperawatan:
PEMERIKSAAN DIAGNOSTIK 1. … … …
2. … … …
 RONTGEN  CT-SCAN  USG  EKG Kriteria Hasil : … … …
 ENDOSKOPI  Lain-lain, ... ...
Intervensi :
Hasil : 1. ………
2. ………

Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan : NAMA TERANG :
 FORMAT PENGKAJIAN KEPERAWATAN KRITIS
PENGKAJIAN DASAR KEPERAWATAN NON TRAUMA

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

1. Identitas Pasien
Nama : ......................................... No. RM : ........................................
Usia : ............ tahun Tgl. Masuk : ........................................
Jenis kelamin : ......................................... Tgl. Pengkajian : ........................................
Alamat : ......................................... Sumber informasi : ........................................
Status pernikahan : ......................................... Agama : ........................................
Suku : ......................................... Pendidikan : ........................................
Pekerjaan : ......................................... Dx.Medis : .......................................

2. Status kesehatan Saat Ini

1. Keluhan utama MRS : ................................................................................................................
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2. Riwayat kesehatan sebelumnya : ..................................................................................................
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3. Data Obyektif
Airway
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Breathing
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 Circulation
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Disability
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Full set of vital sign

 Tekanan darah :……… mmHg

 Suhu :………oC
 Nadi :……... x/menit
 RR :……… x/menit
Five Intervention

Monitor Irama dan rate jantung : ..................................................................................................

.....................................................................................................................................................
Pasang pulse oximetri : ...............................................................................................................
.....................................................................................................................................................
Pasang kateter urine : .................................................................................................................
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Pasang NGT : ..............................................................................................................................
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Pemeriksaan Lab : .......................................................................................................................
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Head to toe examination

1. Kepala & Leher

a. Kepala: ..............................................................................................................................
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b. Mata: ..............................................................................................................................
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c. Hidung: ..............................................................................................................................
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 d. Mulut & tenggorokan:
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e. Telinga:
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f. Leher:
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2. Thorak & Dada:
 Jantung
- Inspeksi: ................................................................................................................................
- Palpasi: ..................................................................................................................................
- Perkusi:..................................................................................................................................
- Auskultasi: .............................................................................................................................
 Paru
- Inspeksi: ................................................................................................................................
- Palpasi: ..................................................................................................................................
- Perkusi:..................................................................................................................................
- Auskultasi: ...............................................................................................................................
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3. Payudara & Ketiak
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4. Punggung & Tulang Belakang
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5. Abdomen
 Inspeksi: .......................................................................................................................................
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 Auskultasi: ....................................................................................................................................
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  Palpasi ........................................................................................................................................
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 Perkusi: ........................................................................................................................................
6. Ekstermitas
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7. Genetalia
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8. Sistem Neurologi
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10. Kulit & Kuku
- Kulit:
...................................................................................................................................................
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Kuku:
...................................................................................................................................................
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4. Catatan Perkembangan
a. Keadaan Umum
JAM

TD

NADI
TTV
RR

SUHU

EYE

GCS MOTORIK

VERBAL

b. Data Penghitungan Balance Cairan

Hari/Tanggal :
Input :
- Minum : ______ ml (Normal: 2000 ml/hari)
- Makan : ______ ml (Normal: 300 ml/hari)
- Infus : ______ ml (Amati saat pengkajian pasien sudah habis berapa
plabot infus)
- Metabolisme : ______ ml (Normal: 5 ml/kgBB/hari)
TOTAL : ______ ml
Output :
- Urin : ______ ml (Normal:1500 ml/kgBB/hari) dicari per-jam
- Feses : ______ ml (Normal:100 ml/hari)
- Keringat : ______ ml (Normal:100 ml/hari)
- IWL : ______ ml (Normal:200 ml/kgBB/hari)
- Cairan NGT : ______ ml (Amati jumlah intake yang saudara masukkan)

TOTAL : ______ ml

TOTAL : ______ ml

Balance (input – output):

 Monitoring cairan tiap jam:

JAM

Minum

Makan
INPUT
Infus

Metabolisme

Urine

Feses

OUTPUT Keringat

IWL

Cairan NGT

Balance cairan Total

5. Hasil Pemeriksaan Penunjang

a. Pemeriksaan Laboratorium
Tanggal & Hasil
Jenis Pemeriksaan Harga Normal Interpretasi
Jam Pemeriksaan
 b. Pemeriksaan Lainya
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6. Terapi
a. Pengobatan
No Nama obat Dosis Rute Manfaat

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
 b. Lainnya
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............................, ………………………201..

Pemeriksa,

(…………………………………………)

NIM
 FORMAT PENGKAJIAN KEPERAWATAN KRITIS
PENGKAJIAN DASAR KEPERAWATANTRAUMA

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

1. Identitas Pasien
Nama : ......................................... No. RM : ........................................
Usia : ............ tahun Tgl. Masuk : ........................................
Jenis kelamin : ......................................... Tgl. Pengkajian : ........................................
Alamat : ......................................... Sumber informasi : ........................................
Status pernikahan : ......................................... Agama : ........................................
Suku : ......................................... Pendidikan : ........................................
Pekerjaan : .........................................

2. Data Subyektif
1. Keluhan utama MRS : ................................................................................................................
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2. Mekanisme Kejadian : ..................................................................................................
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3. SAMPLE
Sign & Symptom
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Allergies
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 Medication
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Past medical history

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Last meal
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Event before accident

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Diagnosa Medis
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3. Data Obyektif
Airway
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Breathing
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Circulation
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 Disability
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Exposure / Environment
.....................................................................................................................................................
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Full set of vital sign

 Tekanan darah :……… mmHg
 Suhu :………oC
 Nadi :……... x/menit
 RR :……… x/menit

Five Intervention
Monitor Irama dan rate jantung : ..................................................................................................
.....................................................................................................................................................
Pasang pulse oximetri : ...............................................................................................................
.....................................................................................................................................................
Pasang kateter urine : .................................................................................................................
.....................................................................................................................................................
Pasang NGT : ..............................................................................................................................
.....................................................................................................................................................
Pemeriksaan Lab : .......................................................................................................................
.....................................................................................................................................................

Give Comfort
.....................................................................................................................................................
.....................................................................................................................................................
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Head to toe examination

1. Kepala & Leher
a. Kepala:
.....................................................................................................................................
b. Mata:
.....................................................................................................................................
c. Hidung:
.....................................................................................................................................
d. Mulut & tenggorokan:
.....................................................................................................................................
e. Telinga:
.....................................................................................................................................
f. Leher:
.....................................................................................................................................
2. Thorak & Dada:
- Inspeksi: ................................................................................................................................
- Palpasi: ..................................................................................................................................
- Perkusi:..................................................................................................................................
- Auskultasi: .............................................................................................................................
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3. Punggung & Tulang Belakang
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4. Abdomen
b. Inspeksi: .......................................................................................................................................
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c. Palpasi: ........................................................................................................................................
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d. Perkusi: ........................................................................................................................................
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e. Auskultasi: ....................................................................................................................................
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5. Genetalia
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6. Ekstremiitas
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7. Kulit & Kuku
a. Kulit: ................................................................................................................................................
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b. Kuku:
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4. Catatan Perkembangan
c. Keadaan Umum
JAM
TD
NADI
TTV
RR
SUHU
EYE
GCS MOTORIK
VERBAL
d. Data Penghitungan Balance Cairan
Hari/Tanggal :
Input :
- Minum : ______ ml (Normal: 2000 ml/hari)
- Makan : ______ ml (Normal: 300 ml/hari)
- Infus : ______ ml (Amati saat pengkajian pasien sudah habis berapa
plabot infus)
- Metabolisme : ______ ml (Normal: 5 ml/kgBB/hari)
TOTAL : ______ ml

Output :
- Urin : ______ ml (Normal:1500 ml/kgBB/hari) dicari per-jam
- Feses : ______ ml (Normal:100 ml/hari)
- Keringat : ______ ml (Normal:100 ml/hari)
- IWL : ______ ml (Normal:200 ml/kgBB/hari)
- Cairan NGT : ______ ml (Amati jumlah intake yang saudara masukkan)

TOTAL : ______ ml

TOTAL : ______ ml

Balance (input – output):

Monitoring cairan tiap jam:
JAM
Minum
Makan
INPUT
Infus
Metabolisme
Urine
Feses
OUTPUT Keringat
IWL
Cairan NGT
Balance cairan Total
5. Hasil Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
Tanggal & Hasil
Jenis Pemeriksaan Harga Normal Interpretasi
Jam Pemeriksaan

b. Pemeriksaan Lainya
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6. Terapi
a. Pengobatan
No Nama obat Dosis Kandungan Manfaat

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

b. Lainnya
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......................, ………………………201..

Pemeriksa,

(…………………………………………)

NIM
 ANALISA DATA

Nama pasien :
Diagnosa medis :
No. RM :

DATA ETIOLOGI MASALAH

DS:

DO:

DS:

DO:
DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN PRIORITAS
NO PRIORITAS DIAGNOSA KEPERAWATAN
1.

2.

3.

Dst.
 INTERVENSI KEPERAWATAN

DIAGNOSA
KEPERAWATAN NOC DAN INDIKATOR NAMA DAN
URAIAN AKTIVITAS
NO TANGGAL DITEGAKKAN / KODE SERTA SKOR AWAL DAN SKOR TTD
RENCANA TINDAKAN (NIC)
DIAGNOSA TARGET PERAWAT
KEPERAWATAN
 IMPLEMENTASI & EVALUASI KEPERAWATAN

DIAGNOSA NAM
EVALUASI
KEPERAWATAN A
N (PERBANDINGAN SKOR AKHIR
DITEGAKKAN /KODE IMPLEMENTASI DAN
O TERHADAP SKOR AWAL DAN
DIAGNOSA TTD
SKOR TARGET)
KEPERAWATAN PERA
WAT

NAMA PASIEN
DX. MEDIS
S O
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: TANGGAL :
: RUANG
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RESUME KEPERAWATAN
A (Dx dan NOC)
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P (NIC)
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I E
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