FALSE
TRIASE / NON
RESUSITASI EMERGENCY URGENT EMERGENC
KATEGORI URGENT
Y
JALAN NAPAS Sumbatan Stridor/disstres Bebas Bebas Bebas
Henti Napas Napas >32x/menit Napas 24-32 Napas Napas
Napas Wheezing x/menit Normal 16- Normal 16-20
PERNAPASAN
<10x/menit Wheezing 20 x//menit x//menit
Sianosis
Henti Nadi tidak Nadi 100-150 Nadi Nadi
Jantung teraba/lemah x/menit Normal Normal
Nadi tidak Bradikardia TD Sistole Luka
teraba/lemah (<50x/mnt) >160 mmHg Perdarahan Ringan
Pucat Takikardia TD Diastole Ringan
Akral Dingin (>150x/mnt) >100 mmHg Cedera
GDA < 80 Pucat Perdarahan Kepala
mg/dl Akral Dingin sedang ringan
SIRKULASI GDA >200 CRT >2 setik Muntah Muntah /
mg/dl TD Sistole <100 dehidrasi diare tanpa
Kejang mmHg Kejang tapi dehidrasi
TD Diastole <60 sadar Nyeri
mmHg Nyeri Sedang ringan
Nyeri akut (>8)
Perdarahan akut
multiple Fraktur
Suhu >39 C
DISABILITY GCS <9 GCS 9-12 GCS >12 GCS 15 GCS 15
AREA P1 P2 P3
RESPON TIME 1 MENIT 10 MENIT 60 MENIT
Pengkajian Perawat, jam: Riwayat Penyakit Dahulu:
Keluhan utama (SAMPLE): TB Kanker Infark Miokard
PPOK Hepatitis Peny.Jantung
DM Hipertensi Stroke
Kejang Asma
Lain2:___________
Riwayat Pemakaian Alkohol:
YA TIDAK Jml/hri:
Riwayat Merokok:
YA TIDAK Jml/hri:
Riwayat Alergi:
YA TIDAK Jenis Alergi:
TD: mmHg Nadi: x/menit SUHU: C TB: cm / BB: Kg
GDA: mg/dl SaO2: % Skala Nyeri (0-10): Status Gizi:
Skala Nyeri Untuk Umur > 9 Tahun: Skala Nyeri Untuk Umur < 9 Tahun: NILAI SKALA
NYERI:
0 (Tidak
Nyeri)
1-3
(Ringan)
4-6
(Sedang)
7-10 (Berat)
DIAGNOSIS MEDIS:
MASALAH
KEPERAWATAN:
JAM IMPLEMENTASI TTD
EVALUASI
(SOAP)
Suhu:
Bila dirujuk/alih rawat, Tanggal: Jam:
SpO2:
GCS:
Malang, 20__
Ttd Perawat
(……………………………)
FORMAT ASUHAN KEPERAWATAN ICU
FORMAT PENGKAJIAN KEPERAWATAN
Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :
Hari rawat ke :
IDENTITAS KLIEN
1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Status Kawin :
5. Suku/ Bangsa :
6. Agama :
7. Pendidikan :
8. Pekerjaan :
9. Alamat :
10. Sumber Biaya :
KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
5. Lain-lain:
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
:………………….....................................................................................................................................
- Genogram :
k. Tracheostomy: ya tidak
......................................................................................................................................................................
......................................................................................................................................................................
l. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
:
...................
...................
...................
Q ..........
R :...................................................................
S :...................................................................
T :...................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
f. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
g. Kandung kemih : Membesar ya tidak
h. Nyeri tekan ya tidak
i. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
j. Balance cairan:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
k. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................
Lokasi :................
Keadaan :................
8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach
b. Tes Audiometri
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
e. Fraktur: ya tidak
- Jenis :...................
f. Traksi: ya tidak
- Jenis :...................
- Beban :...................
- Lama pemasangan :...................
g. Penggunaan spalk/gips: ya tidak
h. Pengkajian Nyeri
Keluhan nyeri: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
i. Sirkulasi perifer: ..............................................
j. Kompartemen syndrome ya tidak
k. Kulit: ikterik sianosis kemerahan hiperpigmentasi
l. Turgor baik kurang jelek
m. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : ...... ....... . ..... ... ... ..... . ...... ...... .. ....
o. Cardinal Sign : ....... ...... .. .... .... .. ...... ...... . ..... ... ..
p. Resiko Jatuh:
MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE
NO PENGKAJIAN SKALA NILAI KET.
1. Riwayat jatuh: apakah lansia pernah jatuh dalam 3 bulan Tidak 0
terakhir? Ya 25
2. Diagnosa sekunder: apakah lansia memiliki lebih dari Tidak 0
satu penyakit? Ya 15
3. Alat Bantu jalan:
q. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
- Warna ...............................................................................................
- Luas luka ...............................................................................................
- Kedalaman ...............................................................................................
- Infeksi ya tidak
- Riwayat luka sebelumya ya tidak
Jika ya:
- Tahun :
- Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya:
- Tahun :
- Lokasi :
f. ABI : ....................................................
g. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
TERAPI MEDIS
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
PERENCANAAN PULANG
- Tujuan Pulang:
- Transportasi Pulang:
- Dukungan Keluarga:
- Pengobatan:
Malang, 2019
(……………………………)
ANALISA DATA
Nama Pasien :
Umur :
No. Register :
Hari/
Tgl/ DATA ETIOLOGI MASALAH
Jam
DIAGNOSA KEPERAWATAN
Nama Pasien :
Umur :
No. Register :
1.
2.
3.
4. dst
PRIORITAS MASALAH KEPERAWATAN
Nama Pasien :
No. Register :
No TANGGAL TANGGAL TANDA
DIAGNOSA KEPERAWATAN
DX MUNCUL TERATASI TANGAN
RENCANA TINDAKAN KEPERAWATAN
Nama pasien :
Umur :
No.Register :
HARI/ DIAGNOSA TUJUAN DAN KRITERIA TINDAKAN KEPERAWATAN PARAF
TGL KEPERAWATAN HASIL
IMPLEMENTASI KEPERAWATAN
Nama pasien :
Umur :
No.Register :
TGL JAM DIAGNOSA KEPERAWATAN TINDAKAN KEPERAWATAN TTD
EVALUASI KEPERAWATAN
Nama pasien :
Umur :
No.Register :
NO DIAGNOSA TANGGAL
KEPERAWATAN
S: ...................................................................... S: S: .....................................................................
. ....................................................................... ..
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
O: O: O:
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
A: A: A:
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
P: P: P:
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... .......................................................................