FORMAT PENGKAJIAN

PRAKTIK KEPERAWATAN KEGAWATDARURATAN

No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...
IDENTITAS

Nama : Jenis Kelamin : L/P Umur :

Agama : Status Perkawinan : Pendidikan :

TRIAGE P1 P2 P3 P4
PRIMER SURVEY

GENERAL IMPRESSION
Keluhan Utama :

Mekanisme Cedera (Jika pasien ada riwayat trauma) :

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...

Diagnosa Keperawatan:

Bersihan jalan nafas tidakefektif b/d …

……
AIRWAY

Jalan Nafas :  Paten  Tidak Paten Kriteria Hasil : … … …

Obstruksi :  Lidah  Cairan  Benda Asing

Intervensi : (saran pisah kotak)
Suara Nafas : Snoring Gurgling
1. Manajemen airway;headtilt-chin lift/jaw
Crowing/Stridor  N/A thrust
2. Pengambilan benda asing dengan
Keluhan Lain: ... ... forcep
3. Suction
4. … …
 Diagnosa Keperawatan:

1. pola nafas tidak efektif b/d … … …

2. Kerusakan pertukaran gas b/d … …
BREATHING …

Gerakan dada:  Simetris  Asimetris Kriteria Hasil : … … …

Irama Nafas :  Cepat  Dangkal  Normal

Intervensi :
Pola Nafas :  Teratur  Tidak Teratur(tambah jenis
1. Pemberian terapi oksigen … …
pernapasan) ltr/mnt, via… …
2. Bantuan dengan Bag Valve Mask
Retraksi otot dada :  Ada  N/A (norrmal) 3. Persiapan ventilator mekanik
4. Mengatur Posisi fowler, semifowler
Sesak Nafas :  Ada  N/A  RR : ... ... x/mnt 5. … …

Keluhan Lain: … …

Diagnosa Keperawatan:

1. Penurunan curah jantung b/d … … …

2. Perfusi jaringan tidakefektif b/d …
CIRCULATION 3. Kelebihan / kekurangan volume
cairan b/d … …

Nadi :  Teraba  Tidak teraba Kriteria Hasil : … … …

Intervensi :
TD/BP :
1. Lakukan CPR dan Defibrilasi
Sianosis :  Ya  Tidak 2. Kontrol perdarahan
3. Pemberian cairan intravena
4. Mengator posisi (Shock position)
Akral dingin  Akral Hangat 
5. Monitor Vital sign
6. Kolaborasi Medikasi
CRT :  ≤3 detik  > 3 detik
7. Monitor irama jantung
Pendarahan :  Ya  Tidak ada (EKG).

Keluhan Lain: ... ...

DISABILITY Diagnosa Keperawatan:

1. Gangguan perfusi serebral b/d … …

2. Risiko cidera...
3. Intoleransi aktivias b/d (pindah ke C)
MER SURVEY
Respon : Alert  Verbal  Pain  Unrespon Kriteria Hasil : … … …

Kesadaran :  CM  Delirium  Somnolen 

Coma , .............................................. Intervensi :

1. Berikan posisi head up 30 derajat

GCS :  Eye ...  Verbal ...  Motorik ... 2. Periksa kesadaran dan GCS tiap 5
menit
Refleks Pupil :  Isokor  Unisokor  Pinpoint  3. … … …
Medriasis 4. … … …
5. … … …
Keluhan Lain : … …

TAMBAHKAN PANDUAN GCS

Diagnosa Keperawatan:

1. Kerusakan integritas jaringan b/d …

……
EXPOSURE 2. Kerusakan mobilitas fisik b/d … … …
3. Hipotermi b/d

Deformitas :  Ya  Tidak Kriteria Hasil : … … …

Contusio :  Ya  Tidak

Abrasi :  Ya  Tidak Intervensi :

Penetrasi : Ya  Tidak 1. Perawatan luka

2. Heacting
Laserasi : Ya  Tidak 3. ………
4. ………
Edema : Ya  Tidak

Luas Luka:

Keluhan Lain:

……

Diagnosa Keperawatan:

1. Regimen terapiutik inefektif b/d … …

…
ANAMNESA 2. Nyeri Akut b/d … … …
3. … … …

Riwayat Penyakit Saat Ini : … … … Kriteria Hasil : … … …

Intervensi :

1. … … …
2. … … …
SECONDARY SURVEY

Alergi :

Medikasi :

Riwayat Penyakit Sebelumnya:

Makan Minum Terakhir:

Even/Peristiwa Penyebab:

Tanda Vital :

BP : N: S: RR :

PEMERIKSAAN FISIK Diagnosa Keperawatan:

1. … … …
2. … … …

Kepala dan Leher: Kriteria Hasil : … … …

 Inspeksi ... ...

Intervensi :

1. … … …
2. … … …

Palpasi ... ...

Dada:

Inspeksi ... ...

Palpasi ... ...

SECONDARY SURVEY

Perkusi ... ...

Auskultasi ... ...

Abdomen:

Inspeksi ... ...

Palpasi ... ...

Perkusi ... ...

Auskultasi ... ...

Pelvis:

Inspeksi ... ...

Palpasi ... ...

Ektremitas Atas/Bawah:

Inspeksi ... ...

Palpasi ... ...

Punggung :

Inspeksi ... ...

Palpasi ... ...

Neurologis :
 Diagnosa Keperawatan:
PEMERIKSAAN DIAGNOSTIK
1. … … …
2. … … …
Kriteria Hasil : … … …

 RONTGEN  CT-SCAN  USG  EKG

Intervensi :
 ENDOSKOPI
1. … … …
 Lab Darah : 2. … … …

 AGD:

 Lain-lain, ... ...

Hasil :

TERAFI/MEDIKASI:
 Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :

Keterangan :

NAMA TERANG :

RESUME PRAKTIK KLINIK KEPERAWATAN KEGAWATDARURATAN

TEMPAT PRAKTIK :............................................................................

NAMA KLIEN : ............................................................................

NO REGISTER : ............................................................................

UMUR : ............................................................................

JENIS KELAMIN : ............................................................................

DIAGNOSA MEDIS : ............................................................................

KELUHAN UTAMA :

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HASIL PEMERIKSAAN FISIK (INSPEKSI, PALPASI, PERKUSI , AUSKULTASI):

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HASIL PEMERIKSAAN PENUNJANG (RADIOGRAFI, HEMATOLOGI, KIMIA DARAH, CT SCAN, MRI, USG,
EKG, DLL):

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TERAPI MEDIS:

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TINDAKAN (KEPERAWATAN DAN MEDIS):

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EVALUASI

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