ASUHAN KEPERAWATAN

Di RUANG IRD

Tanggal pengkajian: ______________________________ Pukul: _________________________

A. PENGKAJIAN
1. Identitas Pasien
Nama : ____________________________________________________________
Umur : ____________________________________________________________
Jenis Kelamin : ____________________________________________________________
Alamat / No. Telp: ____________________________________________________________
Pekerjaan : ____________________________________________________________
Agama : ____________________________________________________________

2. Keluhan utama:
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3. Riwayat penyakit sekarang:

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4. Riwayat penyakit dahulu

⎕ Hipertensi
⎕ DM
⎕ CVA
⎕ IMA
⎕ Dll

5. Usaha pengobatan yang telah dilakukan (pre hospital):

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6. Alergi obat
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7. Pengkajian ABCD dan data fokus

a) Airway (jalan nafas)
Jalan Nafas : ____________________________________________________________
Obstruksi : ____________________________________________________________
Suara nafas : ____________________________________________________________
Keluhan lain : ____________________________________________________________
⎕ Sekret/muntahan ⎕ Darah ⎕ Gurgling ⎕ Snoring ⎕Stridor
⎕ Dll

b) Breathing (pernafasan)
Gerakan dada : ____________________________________________________________
Irama Nafas : ____________________________________________________________
Sesak Nafas : ____________________________________________________________
 Keluhan lain : ____________________________________________________________
⎕ Cyanosis ⎕ Penetrating injury ⎕ Flail chest ⎕ Sucking chest wounds
⎕ Pergeseran trakea ⎕ Suara abnormal pada dada
⎕ Penggunaan otot bantu napas
⎕ Dll

c) Circulation (sirkulasi)
Nadi : ____________________________________________________________
Sianosis : ____________________________________________________________
CRT : ____________________________________________________________
Perdarahan : ____________________________________________________________
Keluhan lain : ____________________________________________________________
⎕ Hipotensi ⎕ Takikardia ⎕ Takipnea ⎕ Hipotermia ⎕ Ekstremitas dingin
⎕ Pucat ⎕ Penurunan capillary refill ⎕ Penurunan produksi urin
⎕ Dll

d) Disability (Tingkat Kesadaran)

Respon : ____________________________________________________________
Kesadaran : ____________________________________________________________
GCS : ____________________________________________________________
Pupil : ____________________________________________________________
Keluhan lain : ____________________________________________________________

e) Exposure
Deformitas : ____________________________________________________________
Contusio : ____________________________________________________________
Abrasi : ____________________________________________________________
Penetrasi : ____________________________________________________________
Laserasi : ____________________________________________________________
Edema : ____________________________________________________________
Keluhan lain : ____________________________________________________________

f) Data fokus
Kepala:
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Leher:
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Thoraks:
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Abdomen:
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Pelvic:
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 Ekstremitas atas dan bawah:
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B. ASSESSMENT (MASALAH)
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C. PERENCANAAN DAN IMPLEMENTASI

1. Prioritas : P1 P2 P3 P4
2. Tindakan keperawatan
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3. Tindakan dan terapi medis

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4. Pemeriksaan Penunjang
a) Laboratorium
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b) Radioogi
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D. EVALUASI
a) Airway
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b) Breathing
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c) Circulation
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d) Disability
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e) Exposure
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