Format Pengkajian Gawat Darurat

Nama : Umur : No. Reg :

…………………………… ………………………….. ……………………...
Alamat :………………......
Jenis Kelamin : Dx. Medis:
……………………………
…………………………… …………………………... ………………………
Alasan Masuk IGD:
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………

Tingkat Kesadaran : AVPU = …………..GCS =…………Four Score =………….

Tanda Vital: TD:……….mmHg Nadi:……..x/menit Suhu:……….0Celcius

RR………….x/menit

Pengkajian Hasil yang didapatkan

Primary Survey
Circulation Nadi karotis : ada / tidak
Frekuensi :………….
Airway Sumbatan Jalan Nafas : ada / tidak
Bunyi Nafas : stridor/gurgling/snoring
Breathing Look : Gerakan dinding dada : ada / tidak
Listen : Suara Nafas : ada / tidak
Feel : rasakan hembusan nafas
Disability GCS =……………
Kekuatan Otot =………….
Refleks Pupil=……………
Ukuran dan kesimtrisan pupil:…………………………………
Exposure D = Deformity…………………………………………………..

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O = Open Wounds……………………………………………....
T = Tenderness………………………………………………….
S = Swelling……………………………………………………..
Folley Kateter : ya/tidak
Kateter Produksi Urin……………….../jam
Gastric Tube Terpasang NGT :………..
Muntah : ya/tidak………jumlah………….cc
EKG Letal / Non Letal
Gambaran…………………………………………………........
…………………………………………………………………..
Secondary Survey
Trauma : Deformities &
DCAP-BTLS Discolorations…………………………………………………..
Crepitus &
Contusions……………………………………………………...
Abrasion &
Avulsion………………………………………………………...
Penetrations &
Punctures……………………………………………………….
Burns &
Bruising…………………………………………………………
Tenderness &
Temperature…………………………………………………….
Lacerations……………………………………………………...
Swelling &
Symmetry……………………………………………………….
SAMPLE S – Signs/Symptoms (tanda/gejala tambahan)
………………………………………………………………….
A – Allergies : ada / tidak
Jenis alergi : …………………………………………………....
M – Medications : pengobatan sebelumnya/obat yang
dikonsumsi :
…………………………………………………………………..
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P – Past Illnesses :
…………………………………………………………………..\
L – Last Oral Intake (Last Menstrual Cycle) :
…………………………………………………………………...
E – Events Leading Up To Present Illness/Injury
…………………………………………………………………...
…………………………………………………………………..
OPQRST Onset of the
Event……………………………………………………………
………………………………………………………………….
Provocation or
Palliation………………………………………………………..
………………………………………………………………….
Quality of the
Pain……………………………………………………………...
…………………………………………………………………..
Region and
Radiation……………………………………………………….
………………………………………………………………….
Severity…………………………………………………………
………………………………………………………………….
Time
(history)………………………………………………………...
………………………………………………………………….

Diagnosa
Intervensi Evaluasi
Keperawatan

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