Anda di halaman 1dari 6

FORMAT PENGKAJIAN

KEPERAWATAN KEGAWATDARURATAN DEWASA

Nama Pasien :....................................................................................................................................


Umur :....................................................................................................................................
Jenis Kelamin :....................................................................................................................................
No Rekam Medik :....................................................................................................................................
Diagnosa Medis :....................................................................................................................................
Tgl Pengkajian :....................................................................................................................................
Jam :....................................................................................................................................
Tgl MRS :....................................................................................................................................

Riwayat Keperawatan
Keluhan Utama ……………………………………………………………………………………….
.
………………………………………………………………………………………
……............................................................................................................................
Riwayat kejadian ……………………………………………………………………………………….
.
………………………………………………………………………………………
…..…………….
…………………………………………………………….........................................
.....................................................................................................................................
..........................................................................................................
Riwayat penyakit .....................................................................................................................................
dahulu .....................................................................................................................................
.....................................................................................................................................
Riwayat Allergi .....................................................................................................................................
....................................................................................................................................
Riwayat medikasi .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Keadaan umum : Baik Sedang Lemah

PENGKAJIAN PIMER
General Assessment : Pediatric Assesment Triangle
Appearance Mental status : Compos mentis Delirium Sopor Somnolen Koma
Muscle tone : Kuat Sedang lemah
:
Body position : ...............................................................................................

Airway 1. Paten: obstruksi jalan nafas (jelaskan) :


2. Vokalisasai
3. Pergerakan udara
Masalah Keperawatan:…..
Tindakan
1. Berikan posisi yang tepat agar jalan nafas tetap paten
2. Identifikasi dan hilangkan sumbatan
3. Berikan oroparingeal, nasoparingeal ETT
4. Lindungi tulang servikalis

Breathing Respiratory Rate : ............... x/menit


Pergerakan dada : simetris asimetri, Jelaskan :.............................................
Penggunaan otot bantu napas : ada tidak ada
Suara napas : vesikuler bronkovesikuler trakea lainnya:jelaskan..
Suara napas tambahan : Tidak ada ronchi rales stridor wheezing
Batuk : Tidak ada ada , produktif tidak produktif
Irama pernapasan : Reguler Ireguler Jelaskan :................................
Masalah Keperawatan:……
Rencnana Tindakan :
1. Auskultasi bunyi pernafasan
2. Posisikan pasien untuk dapat melakukan ventilasi maksimal
3. Berikan oksigen
4. Berikan bantuan nafas dengan mouth to mask, resusitasi, BVM ventilation
5. Tutup bila ada luka terbuka pada dinding dada
6. Turunkan tekanan pada pneumothorak
7. Berikan terapi pada bronkospasme dan oedem pulmonal

SIRKULASI Nadi : ada….x/mnt kualitas/karakter(jelaskan) : tidak ada:


Akral : Hangatkering merah dingin basah
Warna Kulit : Sianosis Jaundice Pucat Normal
Temperatur :…
Jelaskan :.....................................................................................................................
CRT :≤ 2 Dtk > 2Dtk
Turgor kulit : Baik sedang jelek
Edema : tidak ada ada lokasi : (Gambarkan) .................................................
Irama jantung : reguler ireguler Hasil EKG:
Perdarahan : tidak ada ada jenis :.................................................................
Masalah Keperawatan :…
Tindakan
1. Berikan chest compresi/RJP, defibrilasi, dan pengobatan
2. Lakukan perawatan bila ada disritmia
3. Kontrol perdarahan
4. Berikan iV line
5. Terapi cairan dengan cairan isotonis ataupuan tranfusi.

PENGKAJIAN SEKUNDER

General observation
1. Keadaan umum pasien, catat posisi & postur tubuh
2. Pasien tampak menjaga/aktifitas yang melindungi diri
3. Masalah yang tampak terlihat
4. Tingkat stress secara umum
5. Perilaku pasien, tampak tenang, agitasi, letargi, kooperatif, gelisah
6. Pasien dapat melakukan ambulasi, tampak kuat/tegap dalam posisi kuat
7. Pasien dapat melakukan komunikasi verbal, berbicara dengan jelas, konsisten, kebingungan,
cadel, aphasic
8. Pasien tampak bau khas sesuatu, urin, keton, etanol, zat kimia
9. Tanda luka baru ataupun lama akibat injury

PENGKAJIAN PER SISTEM/HEAD to TOE


NEUROLOGI Pupil : isokor anisokor Reflek cahaya : ....../.........
Ukuran Pupil : Normal Midriasis pin point Meiosis Lain2
Jelaskan :...................................................................................................................
Nyeri : Tidak ada ada, Jelaskan
(PQRST):.....................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Reflek
Patologi .......................................................................................................................
.............
....................................................................................................................................
Gangguan Neurologi lain :.........................................................................................
.....................................................................................................................................
Masalah Keperawatan: ................................................................................................................................
.....................................................................................................................................................................
INTEGUMEN
Luka Bakar : tidak ada ada Presentasi Luka bakar :.......................

Abdomen Frekuensi Peristaltik usus : tidak ada normal meningkat menurun


Mual : tidak ada ada Emesis : ada tidak ada
Gangguan Eliminasi : tidak ada ada Jelaskan :...............................................
Masalah Kep :............................................................................................................................................
.....................................................................................................................................................................
Perkemihan Terpasang kateter : tidak ya, jenis :..................................................................
Produksi urin : normal poliuri oliguri anuria (<100cc/hr)
Jelaskan :....................................................................................................................
Masalah Perkemihan : Ada Tidak ada
Jelaskan :................................................................................................................

Masalah Kep : ............................................................................................................................................


.....................................................................................................................................................................
Tindak lanjut KRS MRS PP DOA OPERASI PINDAH LAIN LAIN

PEMERIKSAAN PENUNJANG
Jenis Pemeriksaan
Jam Hasil
Lab/Foto/ECG/lain lain

Pemberian Terapi
Jam Tindakan/ medikasi Keterangan
PERAWATAN INTENSIF
JAM Tensi RR HR SUHU º CVP SPO2 Input Output Medikasi
C (cc) (cc) Obat
TINDAKAN KEPERAWATAN
Waktu Analisa Data Kriteria Hasil Tindakan Evaluasi
Masalah Tujuan :................................... SOAPIE
Kep : .................................................. ..................................................
.........
........................................................... Kriteria Hasil :
............................................................

DATA : (Subyektif & Obyektif)


...........................................................
...........................................................
............................................................
.............................................................
...........................................................
Masalah Kriteria Hasil : SOAPIE
Kep : ..................................................
.........
...........................................................
............................................................

DATA : (Subyektif & Obyektif)


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