PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

BAGIAN KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND

EVALUASI AKHIR SIKLUS

FORMAT PENGKAJIAN ICU/CVCU

Nama Mahasiswa : Defrita Tanggal Praktek: 23 Oktober 2018

No BP :1841312008 Tempat Praktek : CVCU

Nama Pasien : Tn.D..................... Umur : 54 tahun....................................... L

Tanggal masuk RS :21 Oktober 2018 Hari rawat ke : 2

XII. Pengkajian Primer Saat Ini

A: Batuk (+) B: RR = 26 x /i

Sekret kental Pola nafas capat dan dangkal

Warna sekret kuning Penggunaan otot bantu nafas

Irama nafas teratur

C:HR = D:

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

E:

Diagnosa medik :

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

XIII. Pengkajian Sekunder

Kepala

Inspeksi / Palpasi : ............................................................................................................

Keluhan : ............................................................................................................

Mata

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

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

Inspeksi / palpasi : ............................................................................................................

Auskultasi : ............................................................................................................

Thoraks

Inspeksi : ............................................................................................................

Palpasi : ............................................................................................................

Perkusi Paru : ............................................................................................................

Perkusi Jantung : ............................................................................................................

Auskultasi Paru : ............................................................................................................

Pola ventilator : ............................................................................................................

Deskripsi ventilator : ..........................................................................................................

...........................................................................................................................................

Auslkultasi Jantung : ..........................................................................................................

Gambaran EKG : ................................................. JVD : .........................................

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

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

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 atas dan bawah

Inspeksi : ........................................................................................................................

Masa otot : ............................................ Tonus otot : ...........................................

Kekakuan : ............................................ Kejang : .................................................

Berat badan : Tinggi Badan:

XIV. Data Laboratorium

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

XV. Hasil Pemeriksaan Diagnostik lain

XVI. Pengobatan

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

XVII. WOC

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

LEMBAR OBSERVASI

Tanggal Jam

Tingkat Kesadaran
Sistem Ukuran Pupil
Neurologi Reaksi Pupil
GCS
Sistem Jenis Ventilator
Pernafasan PEEP
Frekuensi nafas
Tekanan Darah
MAP
Frekuensi Nadi
Sistem CVP
Kardiovaskuler Suhu Tubuh
PA Sistolik
PA Diastolik
PA mean

Defrita, S.Kep

1841312008
 PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2018

Sat O2
Cairan Enteral
Masuk Parenteral
Lain
Cairan Urin
Keluar Enteral
Lain

Defrita, S.Kep

1841312008