FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Nama Mahasiswa :.........................................................................................................

Semester/Tingkat :.........................................................................................................
Tempat Praktek :.........................................................................................................
Tanggal Pengkajian :.........................................................................................................

DATA KLIEN

A. DATA UMUM
1. Nama inisial klien : .........................................................
2. Umur : .........................................................
3. Alamat : .........................................................
4. Agama : .........................................................
5. Tanggal masuk RS/RB : .........................................................
6. Nomor Rekam Medis : .........................................................
7. Bangsal : .........................................................

B. PENGKAJIAN PRIMER:
1. Respon:
(.....) Alert/sadar
(.....) Verbal
(.....) Pain
(.....) Unrespon
2. Air Way (Jalan Nafas) + Control Servikal
a. Jalan nafas:
(.....) Sesak
(.....) Takipnea (20 – 30 – 40)
(.....) Gasping
(.....) Cyanosis
(.....) Retraksi Supra sternal
(.....) Intra sternal
(.....) Inter sternal
b. Bunyi pernafasan:
(.....) Gurgling (cairan)
(.....) Snoring (lidah)
(.....) Stridor (
c. Control Servikal:
(.....) Trauma Capitis, disertai penurunan kesadaran.
(.....) Trauma tumpul di atas Clavikula.
(.....) Multipel trauma
d. Biomekanik Trauma:
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3. Breathing (Pernafasan) + Control Ventilasi
a. Pulse Oxymetry : .......................
b. Inspeksi :
(.....) sesak; RR : ............. X/mnt.
(.....) jejas pada dada
(.....) luka terbuka pada thoraks
(.....) JVP meningkat
(.....) Deviasi trakea.

Ekpansi thorak Kanan: ............../ Kiri :....................

c. Auskultasi :
1) Dada kanan : (.....) vesikuler; (.....) tidak terdengar/menjauh
 2) Dada kiri : (.....) vesikuler; (.....) tidak terdengar/menjauh

d. Perkusi :
1) Dada kanan : (.....) Sonor, (.....) hipersonor, (.....) dull
2) Dada kiri : (.....) Sonor, (.....) hipersonor, (.....) dull

e. Palpasi :
1) Dada kanan : (.....) nyeri tekan, (.....) krepitasi
2) Dada kiri : (.....) nyeri tekan, (.....) krepitasi

4. Circulation + Control Perdarahan

a. Perdarahan:
1) Eksternal : ...................................................................................................
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2) Internal :
a) Thoraks :................................................................................
b) Abdomen :................................................................................
c) Pelviks :................................................................................
d) Femur :................................................................................
e) Retro perinial :................................................................................

b. Nadi :........................................................................
c. Capilarry refill :........................................................................
d. Akral :.........................................................................
e. Cyanosis :.........................................................................

5. Disability
a. GCS
E: ..... M: ........ V: ......
b. Lateralisasi pupil
1) Pupil : isokor/anisokor
2) Reflek cahaya :............../....................
3) Dilatasi :............../....................
c. Motoric
1) Kekuatan tonus otot :......................................./........................................
2) Lateralisasi motoric :......................................../.......................................

6. Exposure (Cek semua bagian Tubuh)

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7. Foley Catheter
a. Kontra Indikasi
(.....) Perdarahan orifisium urethra eksterna
(.....) Hematom skrotum
(.....) prostat melayang

b. Evaluasi urin :.....................cc/...............jam

8. Gastric Tube
a. Kontra indikasi:
(.....) Braille Hematom
(.....) Rhinorea
 (.....) Othorea
(.....) Echymosis/Battle sign

b. Distensi
Abdominal: ........................................................................................................
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9. Heart Monitor
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C. SECONDERY SURVEY
1. Head to Toe Examination (BTLS) :
a. Kepala :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

b. Leher :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

c. Thoraks :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

d. Abdomen.
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

e. Pelvis :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

f. Ektremitas
1. Atas :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

2. Bawah:
- B : ..............................................................................................................
 - T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

2. Vital Sign
a. Frekuensi Nadi : ....................x/mnt.
b. Tekanan darah :......................mmHg
c. Frekuensi pernafasan :......................x/mnt
d. Suhu :…...................oC
e. Saturasi oksigen :.......................%

3. Finger in every orifice (colok semua lubang)

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4. Anamnesa KOMPAK
a. K : ..............................................................................................................
b. O : ..............................................................................................................
c. M : ...............................................................................................................
d. P : ...............................................................................................................
e. A : ...............................................................................................................
f. K : ...............................................................................................................

5. Pemeriksaan tambahan
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6. Persiapan rujuk: ke rumah sakit atau ruangan lain

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D. Reevaluasi

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FORMAT PEMBUATAN ASKEP

I. ANALISA DATA
NO HARI/TGL DATA FOKUS ETIOLOGI PROBLEM TTD
DS
DO

II. DIAGNOSA KEPERAWATAN ( PRIORITAS MASALAH )

HARI/TGL DX KEPERAWATAN TGL TERATASI TTD
NO
DS
DO

III. RENCANA KEPERAWATAN

NO.DP HARI/TGL TUJUAN INTERVENSI RASIONAL TTD
DS
DO

IV. CATATAN KEPERAWATAN

NO.DP HARI/TGL/JAM TINDAKAN RESPON HASIL TTD
DS
DO

V. CATATAN PERKEMBANGAN
NO.DP HARI/TGL/JAM EVALUASI TTD
S :
O:
A:
P: