FORMAT PENGKAJIAN KEPERAWATAN

GAWAT DARURAT DAN KRITIS

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT DAN KRITIS

I. Identitas Mahasiswa
Nama : ...............................................................
NIM : ...............................................................

II. Identitas Klien

Nama : ...............................................................
Umur : ...............................................................
No MR : ...............................................................
Jenis Kelamin : ...............................................................
Tanggal : ...............................................................
BB : ...............................................................
Agama : ...............................................................
Status :................................................................
Pendidikan : ...............................................................
Pekerjaan :................................................................
Alamat rumah : ...............................................................
Diagnosa medis : ...............................................................

III. DATA KHUSUS

1. Subjektif
a. Keluhan Utama
b. SAMPLE
1) Sympton
2) Alergies
3) Medication
4) Penyakit yang diderita
5) Last meal (makan terakhir)
6) Event (kejadian sebelum cedera)
2. Objektif
a. Airway
b. Breathing
c. Circulation
d. Disability
e. Exposure & environment
f. Full set of vital sign, five intervention
g. Give comport (memberi kenyamanan)
h. History
3. Head to to assessment
4. Pemeriksaan penunjang

IV. ANALISA DATA

NO DATA ETIOLOGI PROBLEM

PROGRAM PROFESI NERS PROGRAM STUDI S1 ILMU

KEPERAWATAN Page 1
FORMAT PENGKAJIAN KEPERAWATAN
GAWAT DARURAT DAN KRITIS

V. Daftar Diagnosa Keperawatan Berdasarkan Prioritas

1. ..................................................................................................................................
2. Dst …

VI. Intervensi Keperawatan

No. Tujuan &
Tgl Dx. Kep Intervensi Rasional
Dx KH

VII. Implementasi Keperawatan

NO. DX TGL / JAM IMPLEMENTASI TTD

VIII. Evaluasi
TGL /
DX. NO S O A P
JAM

PROGRAM PROFESI NERS PROGRAM STUDI S1 ILMU

KEPERAWATAN Page 2
FORMAT PENGKAJIAN KEPERAWATAN
GAWAT DARURAT DAN KRITIS

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT DAN KRITIS RUANG

ICU/ICCU

I. Identitas Mahasiswa
Nama : ............................................
NIM : ............................................

II. Identitas Klien

Nama : ............................................,
Umur : .................................
No MR : ............................................,
Jenis Kelamin : ................................................
Tanggal : ............................................,
BB : .................................
Agama : ............................................,
Status :..................................
Pendidikan : ............................................,
Pekerjaan : ...............................................................
Alamat rumah :.................................................................
Diagnosa medis :...............................................................…

III. Keluhan utama

a. Saat MRS (Tgl..................Jam....................)
……………………………………………………………………………………………….
……………………………………………………………………………………………….
b. Saat Pengkajian (Tgl……..Jam…………….)
……………………………………………………………………………………………….
……………………………………………………………………………………………….
c. Alasan dirawat di ICU
..................................................................................................................................
...............................................................................................................................…

IV. Primary Survey

Air way :
Breathing : RR: pola nafas: sianosis: SpO2: I + Pl + Pr + A
Circulation : TD: MAP: N: EKG ditambah I + Pl + Pr + A
Fluid :

V. Secondary Survey
1) Brain
GCS, pupil (reaksi & Φ), RC, pelo, kesemutan, tremor, kejang, bingung,
gelisah, mencong, nyeri
Cth Ndx: Penurunan kesadaran, ggn koordinasi, ggn mobilitas fisik, ggn
perfusi jaringan otak, res. Injuri, ggn komunikasi verbal, cemas.
2) Breathing
Batuk, nafas bunyi, lendir, sesak, nyeri nafas, cuping hidung, ist/akt, tipe;
perut/ dada/biot,dst.
Cth Ndx: Pola nafas, gas exchange, airway

PROGRAM PROFESI NERS PROGRAM STUDI S1 ILMU

KEPERAWATAN Page 3
FORMAT PENGKAJIAN KEPERAWATAN
GAWAT DARURAT DAN KRITIS

3) Blood
Nyeri dada, pulsasi, pusing, pingsan, perdarahan, odema, hematom.
Cth Ndx: Syok cardiogenik, ggn perfusi, nyeri, kesadran menurun.
4) Bladder
Nyeri pinggang, b.a.k: warna, lancar/netes/nyeri/retensi/inkontenensia/alat
bantu, frekuensi, benjolan
CthNdx: Ggn pola, ggn keseimbangan cairan/elektrolit, nyeri.
5) Bowel
B.a.b; pola/konsistensi/warna, kembung, BU, NT, lokasinya
Cth Ndx: Ggn pola, ggn keseimbangan cairan/elektrolit, nyeri.
6) bone
Nyeri otot/tulang, kaku sendi, bengkak, patah tulang dimana, pergerakannya
Cth Ndx: Nyeri, ggn aktifitas, resiko infeksi

VI. Pemeriksaan penunjang

VII. ANALISA DATA

No Data Etiologi Problem

VIII. Daftar Diagnosa Keperawatan Berdasarkan Prioritas

1. ..................................................................................................................................
2. ………………………………………………………………………………………………
3. ……………………………………………………………………………………………..
4. Dst …

IX. INTERVENSI KEPERAWATAN

No. Tujuan &
Tgl Dx. Kep Intervensi Rasional
Dx KH

X. IMPLEMENTASI KEPERAWATAN
No. Dx Tgl / Jam Implementasi Ttd

XI. EVALUASI
Dx. No Tgl / Jam S O A P

PROGRAM PROFESI NERS PROGRAM STUDI S1 ILMU

KEPERAWATAN Page 4