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KEMENTRIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENTRIAN KESEHATAN DENPASAR


JURUSAN KEPERAWATAN
Alamat : Jl. Pulau Moyo No 33 A , Denpasar Selatan
Telp : (0361) 725273 FAX : (0361) 724568

FORMAT PENGKAJIAN
KEPERAWATAN GAWAT DARURAT

Nama Mahasiswa :
NIM :

Identitas Pasien :
Nama : Tn. S
Umur : 60 tahun
Jenis Kelamin : laki-laki
Pekerjaan : pensiunan
Agama : Hindu
Tanggal Masuk RS : 02 September 2019
Alasan Masuk : pasien mengeluh nyeri dada kiri
Diagnosa Medis :

Initial survey:
A (alertness) : √
V (verbal) :-
P (pain) :-
U (unserpons) : -

Warna triase : P1 P2 P3 P4 P5
SURVEY PRIMER DAN RESUSITASI

AIRWAY DAN KONTROL SERVIKAL

1. Keadaan jalan nafas

Tingkat kesadaran : composmentis


Pernafasan : dispnea (26x/menit)
Upaya bernafas : ada
Benda asing di jalan nafas : tidak ada

Bunyi nafas : vesikuler

Hembusan nafas : ada

2. Diagnosa Keperawatan
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3. Intervensi / Implementasi
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4. Evaluasi
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BREATHING
Fungsi pernafasan
Jenis Pernafasan : dispnea
Frekwensi Pernafasan : 26x/menit, irama tidak teratur
Retraksi Otot bantu nafas : tidak ada
Kelainan dinding thoraks : simetris
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Bunyi nafas : vesikuler
Hembusan nafas : ada
Saturasi : 90 %

2. Diagnosa Keperawatan
1. Pola napas tidak efektif berhubungan dengan

3. Intervensi / Implementasi

4. Evaluasi
CIRCULATION
Keadaan sirkulasi
Tingkat kesadaran : composmentis
Perdarahan (internal/eksternal) : tidak ada
Kapilari Refill : < 3 detik
Tekanan darah : 170/100 mmHg
Nadi radial/carotis : 100 x / menit
Akral perifer : Dingin

2. Diagnosa Keperawatan
1. Penurunan curah jantung berhubungan dengan perubahan afterload
2. Resiko perfusi miokard tidak efektif dibuktikan dengan faktor resiko hipertensi

3. Intervensi / Implementasi
Standar Luaran Standar Intervensi
No Diagnosa Keperawatan Keperawatan Indonesia Keperawatan Indonesia
(SLKI) (SIKI)
1 Penurunan curah jantung Setelah dilakukan tindakan
berhubungan dengan keperawatan 1 x 2 jam
perubahan afterload diharapkan curah jantung
meningkat dengan kriteria
hasil :
1. Lelah menurun (5)
2. Dispnea menurun (5)
3. Tekanan darah
membaik (normal
120/80 mmHg)
2 Resiko perfusi miokard Setelah dilakukan tindakan
tidak efektif dibuktikan keperawatan 1 x 2 jam
dengan faktor resiko diharapkan perfusi miokard
hipertensi dengan kriteria hasil :
1. Nyeri dada menurun (1)
2. Tekanan darah membik
(100/80 – 120/80 mmHg)
3. Denyut nadi radial
membaik (5)

4. Evaluasi

DISABILITY
Pemeriksaan Neurologis:
GCS : E 4 V5 M 5 : 14
Reflex fisiologis : Reflek pupil +/+
Reflex patologis :
Kekuatan otot:
2. Diagnosa Keperawatan
1. Nyeri akut berhubungan dengan agen pencedera fisiologis (misal : inflamasi, iskemia,
neoplasma).

3. Intervensi / Implementasi
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4. Evaluasi
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PENGKAJIAN SEKUNDER / SURVEY SEKUNDER
(Dibuat bila pasien lebih dari 2 jam diobservasi di IGD)

1. RIWAYAT KESEHATAN
a. RKD
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b. RKS
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c. RKK
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2. RIWAYAT DAN MEKANISME TRAUMA


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3. PEMERIKSAAN FISIK (HEAD TO TOE)

a. Kepala
Kulit kepala :..........................................................................................................
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Mata :..........................................................................................................
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Telinga :..........................................................................................................
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Hidung :..........................................................................................................
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Mulut dan gigi :..........................................................................................................
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Wajah :..........................................................................................................
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Leher :..........................................................................................................
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b. Dada/ thoraks
Paru-paru
Inspeksi :..........................................................................................................
Palpasi :.........................................................................................................
Perkusi :..........................................................................................................
Auskultasi :..........................................................................................................

Jantung
Inspeksi :..........................................................................................................
Palpasi :..........................................................................................................
Perkusi :..........................................................................................................
Auskultasi :..........................................................................................................

c. Abdomen
Inspeksi :..........................................................................................................
Palpasi :..........................................................................................................
Perkusi :..........................................................................................................
Auskultasi :..........................................................................................................

d. Pelvis
Inspeksi :..........................................................................................................
Palpasi :..........................................................................................................

e. Perineum dan rektum : .........................................................................................................

f. Genitalia : .........................................................................................................
g. Ekstremitas
Status sirkulasi :..........................................................................................................
Keadaan injury :..........................................................................................................

h. Neurologis
Fungsi sensorik :

Fungsi motorik :
4. HASIL LABORATORIUM
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5. HASIL PEMERIKSAAN DIAGNOSTIK
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6. TERAPI DOKTER
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B. ANALISIS DATA
Data fokus Analisis Masalah

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C. DIAGNOSA KEPERAWATAN DAN PRIORITAS MASALAH
E. PELAKSANAAN

Tgl/jam No Implementasi Respon Paraf


Dx

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F. EVALUASI
Tgl / jam No Catatan Perkembangan (SOAP) Paraf
Dx

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RESUME DAN PERENCANAAN PASIEN PULANG

INFORMASI PEMINDAHAN RUANGAN/PEMULANGAN PASIEN

INFORMASI √ KETERANGAN

Di Ruang : _____________________________
[ ] Foto Rontgen : _______________________ [ ] Laboratorium: ___ lembar
[ ] EKG : ___ lembar
[ ] Obat-obatan :

MRS

Dipulangkan [ ] KIE [ ] Obat pulang [ ] Foto Rontgen


[ ] Laboratorium [ ] Kontrol Poliklinik, tanggal ______/______/______

Pulang paksa [ ] KIE [ ] Tanda tangan pulang paksa

Meninggal Dinyatakan meninggal pukul ______._______ WITA

Minggat Dinyatakan minggat pukul ______._______ WITA

Nama dan tanda tangan perawat pengkaji

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