PraktekProfesiKeperawatanGawatDarurat

FakultasKeperawatanUNAND 2019

BAGIAN KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND

FORMAT PENGKAJIAN

Nama Mahasiswa : ............................................ Tanggal Praktek : ..........................

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

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

I. Pengkajian Primer
A: B:

C: D:

Elsy Sovianty
1841312091
 PraktekProfesiKeperawatanGawatDarurat
FakultasKeperawatanUNAND 2019

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 : ........................................................................................................................
........................................................................................................................

III. Status Kesehatan Saat Ini

Alasan Kunjungan/keluhan utama:

Faktor pencetus:

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

Faktor yang memperberat:

Elsy Sovianty
1841312091
 PraktekProfesiKeperawatanGawatDarurat
FakultasKeperawatanUNAND 2019

Upaya yang dilakukan untuk mengatasi:

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

Pola Eliminasi :
Buang air besar
Frekwensi : ...................................... Waktu : .....................................
Warna : ...................................... Konsistensi : .........................
Kesulitan : ................................................................................................

Elsy Sovianty
1841312091
 PraktekProfesiKeperawatanGawatDarurat
FakultasKeperawatanUNAND 2019

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 : .............................................................................................

Pola Bekerja
Jenis pekerjaan : ...................................................... Lama bekerja : ......................
Jadwal kerja : ...................................................... Jumlah jam kerja : .....................

V. Riwayat Keluarga
Genogram beserta penyakit yang dialami oleh anggota keluarga lain

Elsy Sovianty
1841312091
 PraktekProfesiKeperawatanGawatDarurat
FakultasKeperawatanUNAND 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 : ............................................................................................
Leher
Inspeksi / palpasi : ............................................................................................................
Auskultasi : ............................................................................................................
Thoraks
Inspeksi : ............................................................................................................
Palpasi : ............................................................................................................
Perkusi Paru : ............................................................................................................
Perkusi Jantung : ............................................................................................................
Auskultasi Paru : ............................................................................................................
Pola ventilator : ............................................................................................................
Deskripsi ventilator : ..........................................................................................................
...........................................................................................................................................
Auslkultasi Jantung : ..........................................................................................................
Gambaran EKG : ................................................. JVD : .........................................

Elsy Sovianty
1841312091
 PraktekProfesiKeperawatanGawatDarurat
FakultasKeperawatanUNAND 2019

Sirkulasi
Frekwensi nadi : ......................................... Sa O2 : ..................................................
Tekanan darah : ........................... MAP : ........................ CVP : .................
PA Sistolik : ........................... PA Diastolik : ................ PAP : .................
Suhu tubuh : ........................... Suhu ekstremitas : ............................................
Sianosis : Bibir / kuku ...................... Pucat : ...................................................
Turgor : ............................................................................................................

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 : .................................................

Elsy Sovianty
1841312091
 PraktekProfesiKeperawatanGawatDarurat
FakultasKeperawatanUNAND 2019

VII. Data Laboratorium

VIII. Hasil Pemeriksaan Diagnostik lain

IX. Pengobatan

Elsy Sovianty
1841312091
 PraktekProfesiKeperawatanGawatDarurat
FakultasKeperawatanUNAND 2019

X. Kesimpulan

XI. DAFTAR PUSTAKA

Elsy Sovianty
1841312091