PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2019

BAGIAN KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND

FORMAT PENGKAJIAN

Nama Mahasiswa : Suci Indah Putri Tanggal Praktek : ..........................

No BP : 1841312096 Tempat Praktek : ..........................

Nama Pasien : ............................................... Umur : ....................................... L/P

I. Pengkajian Primer

A: B:

C: D:

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

E:

II. Data Demografi

Nama Lengkap : ........................................................ Tanggal masuk RS : ..................

Tempat/tgl lahir : ........................................................ Status perkawinan : ..................

Agama : ........................................................ Suku : ..................

Pendidikan : ........................................................

Pekerjaan : ........................................................ Lama bekerja : ..................

Alamat : ........................................................................................................................

........................................................................................................................

Sumber Informasi : ............................................................................................................

Keluarga terdekat yang dapat dihubungi:

Nama : .......................................................

Pendidikan : ....................................................... Pekerjaan : ..........................

Alamat : ........................................................................................................................

........................................................................................................................

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

III. Status Kesehatan Saat Ini

Alasan Kunjungan/keluhan utama:

Faktor pencetus:

Lamanya keluhan: .................................................................. Mendadak / Bertahap

Faktor yang memperberat:

Upaya yang dilakukan untuk mengatasi:

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

Diagnosa Medik:

.......................................................................... Tanggal .......................................

.......................................................................... Tanggal .......................................

.......................................................................... Tanggal .......................................

IV. Riwayat Kesehatan yang lalu

Penyakit yang pernah dialami (jenis penyakit, lama dan upaya mengatasi)

Alergi : ........................................................................................................................................

Kebiasaan : merokok / kopi / alkohol / lain-lain ..........................................................................

Obat-obatan yang sering digunakan (nama dan frekwensi)

Pola Nutrisi :

Berat badan : ........................................................ Tinggi badan : ...........................

Frekwensi makan : ............................................................................................................

Jenis makanan : ................................................................................................

Makanan yang disukai : ................................................................................................

Makanan yang tidak disukai : ............................................................................................

Nafsu makan dalam 6 bulan terakhir : Baik / Sedang / Kurang

Perubahan berat badan 6 bulan terakhir : ..................... Kg Bertambah / Berkurang

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

Pola Eliminasi :

Buang air besar

Frekwensi : ...................................... Waktu : .....................................

Warna : ...................................... Konsistensi : .........................

Kesulitan : ................................................................................................

Buang air kecil

Frekwensi : ...................................... Warna : .........................

Kesulitan : ................................................................................................

Pola tidur dan istirahat

Lama tidur : .................................................. Waktu : .....................................

Kesulitan dalam hal tidur : ................................................................................................

Pola aktivitas dan latihan

Kegiatan dalam pekerjaan : ...............................................................................................

Olah raga rutin (jenis dan frekwensi) :

............................................................................................................................................

............................................................................................................................................

Kegiatan di waktu luang : ..................................................................................................

Keluhan dalam beraktivitas : .............................................................................................

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

Pola Bekerja

Jenis pekerjaan : ...................................................... Lama bekerja : ......................

Jadwal kerja : ...................................................... Jumlah jam kerja : .....................

V. Riwayat Keluarga

Genogram beserta penyakit yang dialami oleh anggota keluarga lain

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

VI. Pengkajian Sekunder

Kepala

Inspeksi / Palpasi : ............................................................................................................

Keluhan : ............................................................................................................

Mata

Fungsi penglihatan : .................................................. Palpebra : Terbuka / tertutup

Ukuran pupil : .......................................................................... Isokor / Unisokor

Akomodasi : .......................................................................... Isokor / Unisokor

Konjungtiva : .................................................... Sklera : .....................................

Edema Palpebra : ............................................................................................................

Keluhan : ............................................................................................................

Telinga

Fungsi Pendengaran : ............................................ Fungsi keseimbangan : .............

Keluhan : ............................................................................................................

Hidung dan sinus

Inspeksi : ............................................................................................................

Pembengkakan : ................................................. Pendarahan : ............................

Keluhan : ...........................................................................................................

Mulut dan tenggorok

Inspeksi : ...........................................................................................................

Keadaan gigi : ...........................................................................................................

Keadaan membran mukosa : ............................................................................................

Kesulitan menelan : ............................................................................................

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

Leher

Inspeksi / palpasi : ............................................................................................................

Auskultasi : ............................................................................................................

Thoraks

Inspeksi : ............................................................................................................

Palpasi : ............................................................................................................

Perkusi Paru : ............................................................................................................

Perkusi Jantung : ............................................................................................................

Auskultasi Paru : ............................................................................................................

Pola ventilator : ............................................................................................................

Deskripsi ventilator : ..........................................................................................................

...........................................................................................................................................

Auslkultasi Jantung : ..........................................................................................................

Gambaran EKG : ................................................. JVD : .........................................

Sirkulasi

Frekwensi nadi : ......................................... Sa O2 : ..................................................

Tekanan darah : ........................... MAP : ........................ CVP : .................

PA Sistolik : ........................... PA Diastolik : ................ PAP : .................

Suhu tubuh : ........................... Suhu ekstremitas : ............................................

Sianosis : Bibir / kuku ...................... Pucat : ...................................................

Turgor : ............................................................................................................

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

Abdomen

Inspeksi : ............................................................................................................

Auskultasi : ............................................................................................................

Palpasi : ............................................................................................................

Perkusi : ............................................................................................................

Jenis diet : .......................................... Nafsu makan : .....................................

Pengeluaran NGT : ............................................................................................................

Frekwensi BAB : .......................................... Konsistensi feses : ................................

Keluhan makan dan BAB : ................................................................................................

Frekwensi BAK : ........................................ Volume Urin : .....................................

Penggunaan kateter : .................................... Hematuri : .....................................

Keluhan BAK : ............................................................................................................

Riwayat Kehamilan : ..........................................................................................................

Perdarahan pervaginam : ................................................................................................

Keluhan sistem reproduksi : ..............................................................................................

Ekstremitas

Inspeksi : ........................................................................................................................

Masa otot : ............................................ Tonus otot : ...........................................

Kekakuan : ............................................ Kejang : .................................................

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

VII. Data Laboratorium

VIII. Hasil Pemeriksaan Diagnostik lain

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1841312096
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2019

IX. Pengobatan

X. Kesimpulan

XI. DAFTAR PUSTAKA

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1841312096