FORMAT ASUHAN KEPERAWATAN

DI RUANG IRD

Tanggal Pengkajian :
Pukul :

A. PENGKAJIAN
1. Identitas Pasien
Nama : ________________________________________________________
Umur : ________________________________________________________
Jenis Kelamin : ________________________________________________________
Alamat : ________________________________________________________
No. Telpon : ________________________________________________________
Pekerjaan : ________________________________________________________
Agama : ________________________________________________________

2. Keluhan utama : ________________________________________________________

3. Riwayat Penyakit Sekarang :
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4. Riwayat Penyakit Dahulu :
Hipertensi
Diabetes Melitus
CVA
IMA

5. Usaha Pengobatan yang Telah Dilakukan (pre Hospital) :

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6. Alergi Obat : ________________________________________________________
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7. Pengkajian ABCD :
A (Airway)
Sekret/Muntahan
Darah
Gurgling
Snoring
Stridor

B (Breathing)
Sianosis Penggunaan otot bantu pernafasan
Penetatring injury Pergeseran trakea
Flail chest Suara Abnormal dada
Sucking chest wounds
 C (Circulation) D (Disability) : GCS
Hipotensi E
Takikardia V
Takipnea M
Hipotermia
Pucat
Ekstremitas dingin
Penurunan Capilary Refill
Penurunan Produksi urin

AVPU :
Alert : ________________________________________________________
Vocalises : ________________________________________________________
Responds to Pain only : ___________________________________________________
Unresposive to pain : ____________________________________________________

Data Fokus (pemeriksaan fisik)

Kepala : ________________________________________________________
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Leher : ________________________________________________________
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Thorak : ________________________________________________________
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Abdomen : ________________________________________________________
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Pelvis : ________________________________________________________
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Ekstremitas : ________________________________________________________
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B. ASSESMENT (Masalah)
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C. INTERVENSI DAN IMPLEMENTASI

1. Priotitas
P1
P2
P3
P4
2. Implementasi Keperawatan
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3. Tindakan dan Terapi Medis
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4. Pemeriksaan Penunjang
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D. EVALUASI
Airway : __________________________________________________________
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Breathing : __________________________________________________________
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Circulation : __________________________________________________________
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Disability : __________________________________________________________
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Tanda Tangan

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