FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Nama Mahasiswa :.........................................................................................................

Semester/Tingkat :.........................................................................................................
Tempat Praktek :.........................................................................................................
Tanggal Pengkajian :.........................................................................................................

DATA KLIEN

A. DATA UMUM
1. Nama inisial klien : .........................................................
2. Umur : .........................................................
3. Alamat : .........................................................
4. Agama : .........................................................
5. Tanggal masuk RS/RB : .........................................................
6. Nomor Rekam Medis : .........................................................
7. Bangsal : .........................................................

B. PENGKAJIAN PRIMER:
1. Respon:
(.. . .) Alert/sadar
(.. . .) Verbal
(.. . .) Pain
(.. . .) Unrespon
2. Air Way (Jalan Nafas) + Control Servikal
a. Jalan nafas:
(.. . .) Sesak
(.. . .) Takipnea (20 – 30 – 40)
(.. . .) Gasping
(.. . .) Cyanosis
(.. . .) Retraksi Supra sternal
(.. . .) Intra sternal
(.. . .) Inter sternal
b. Bunyi pernafasan:
(.. . .) Gurgling (cairan)
(.. . .) Snoring (lidah)
(.. . .) Stridor (
c. Control Servikal:
(.. . .) Trauma Capitis, disertai penurunan kesadaran.
(.. . .) Trauma tumpul di atas Clavikula.
(.. . .) Multipel trauma
d. Biomekanik Trauma:
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3. Breathing (Pernafasan) + Control Ventilasi
a. Pulse Oxymetry : .......................
b. Inspeksi :
(.....) sesak; RR.................X/mnt.
(.. . .) jejas pada dada
(.. . .) luka terbuka pada thoraks
(.. . .) JVP meningkat
(.. . .) Deviasi trakea.

Ekpansi thorak Kanan: ............../ Kiri :....................

 c. Auskultasi :
1) Dada kanan : (.....) vesikuler; (.....) tidak terdengar/menjauh
2) Dada kiri : (.....) vesikuler; (.....) tidak terdengar/menjauh

d. Perkusi :
1) Dada kanan : (.....) Sonor, (.....) hipersonor, (.....) dull
2) Dada kiri : (.....) Sonor, (.....) hipersonor, (.....) dull

e. Palpasi :
1) Dada kanan : (.....) nyeri tekan, (.....) krepitasi
2) Dada kiri : (.....) nyeri tekan, (.....) krepitasi

4. Circulation + Control Perdarahan

a. Perdarahan:
1) Eksternal :
...........................................................................................................................
...............................................................................................................
2) Internal :
a) Thoraks :................................................................................
b) Abdomen :................................................................................
c) Pelviks :................................................................................
d) Femur :................................................................................
e) Retro perinial :................................................................................

b. Nadi :........................................................................
c. Capilarry refill :........................................................................
d. Akral :.........................................................................
e. Cyanosis :.........................................................................

5. Disability
a. GCS
E: ..... M: ........ V: ......
b. Lateralisasi pupil
1) Pupil : isokor/anisokor
2) Reflek cahaya :............../....................
3) Dilatasi :............../....................
c. Motoric
1) Kekuatan tonus otot :......................................./........................................
2) Lateralisasi motoric :......................................../.......................................

6. Exposure (Cek semua bagian Tubuh)

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7. Foley Catheter
a. Kontra Indikasi
(.. . .) Perdarahan orifisium urethra eksterna
(.. . .) Hematom skrotum
(.. . .) prostat melayang

b. Evaluasi urin :.....................cc/...............jam

 8. Gastric Tube
a. Kontra indikasi:
(.. . .) Braille Hematom
(.. . .) Rhinorea
(.. . .) Othorea
(.. . .) Echymosis/Battle sign

b. Distensi Abdominal:
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9. Heart Monitor
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C. SECONDERY SURVEY
1. Head to Toe Examination (BTLS) :
a. Kepala :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

b. Leher :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

c. Thoraks :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

d. Abdomen.
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

e. Pelvis :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

f. Ektremitas
1. Atas :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................
 2. Bawah:
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

2. Vital Sign
a. Frekuensi Nadi.........................................x/mnt.
b. Tekanan darah..........................................mmHg
c. Frekuensi pernafasan................................x/mnt
d. Suhu...........................................................oC
e. Saturasi oksigen.........................................%

3. Finger in every orifice (colok semua lubang)

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4. Anamnesa KOMPAK
a. K : ..............................................................................................................
b. O : ..............................................................................................................
c. M : ...............................................................................................................
d. P : ...............................................................................................................
e. A : ...............................................................................................................
f. K : ...............................................................................................................

5. Pemeriksaan tambahan
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6. Persiapan rujuk: ke rumah sakit atau ruangan lain

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D. Reevaluasi

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 F ORMAT PEMBUATAN ASKEP
I. ANALISA DATA
NO HARI/TGL DATA FOKUS ETIOLOGI PROBLEM TTD
DS
DO

II. DIAGNOSA KEPERAWATAN ( PRIORITAS MASALAH )

NO HARI/TGL DX KEPERAWATAN TGL TTD
TERATASI
DS
DO

III. RENCANA KEPERAWATAN

NO.DP HARI/TGL TUJUAN INTERVENSI RASIONAL TTD
DS
DO

IV. CATATAN KEPERAWATAN

NO.DP HARI/TGL/JAM TINDAKAN RESPON HASIL TTD
DS
DO

V. CATATAN PERKEMBANGAN
NO.DP HARI/TGL/JAM EVALUASI TTD
S :
O:
A:
P: