ASUHAN KEPERAWATAN DEPARTEMEN GAWAT

DARURAT PADA PASIEN :​............

................................................... ​DENGAN KASUS : ​.....
......................................................... ​DI RS :​...
............................................................ ​TANGGAL :
...............................................................

Nama Lengkap :

NIM :

PROGRAM STUDI PROFESI NERS FAKULTAS ILMU

KESEHATAN UNIVERSITAS TRIBHUWANA
TUNGGADEWI MALANG 2019/20
 PENGKAJIAN KEPERAWATAN GAWAT
DARURAT

Tanggal Pengkajian : ................................................... No. RM :

Nama Lengkap : ................................................... Jenis Kelamin : Pria/ Wanita

Tanggal Lahir : ................................................... Penanggungjawab: .........................................................

Alamat : ......................................................................................................... RT/RW: .........................

Kondisi Saat Masuk : Mandiri Tempat Tidur Dipapah Lainnya: ........................

Asal pasien : Rujukan Datang Sendiri Polisi Lainnya: ........................

Cara datang : Ambulance Kendaraan Pribadi Kendaraan Umum Lainnya: ........................

Tingkat Kegawatan : Merah Kuning Hijau Hitam

SUBYEKTIF Jam: ...........................

Keluhan Utama : ..............................................................................................................................................

Anamnesis : ..............................................................................................................................................

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Riwayat Penyakit Lalu : ..............................................................................................................................................

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Riwayat Pengobatan : ..............................................................................................................................................

Riwayat Alergi : ..............................................................................................................................................

Kecelakaan Lantas : (Ya/Tdk)*............... vs ............... Tgl/Jam Kejadian: ...................../............ Tempat:

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

Mekanisme kejadian : ..............................................................................................................................................

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PENGKAJIAN KEPERAWATAN PRIMER

A. ​Airway ​Paten Tidak paten: Snoring/ Gargling/ Stridor/ Benda asing. Lainnya: ........................

Masalah Keperawatan: Bersihan jalan nafas tidak efektif

B. ​Breathing

Irama nafas : Reguler Irreguler

Suara nafas : Vesikuler Wheezing Ronchi Crackles Redup

 Pola nafas : Apneu Dispneu Bradipneu Takipneu Orthopneu

Jenis nafas : Pernafasan dada Pernafasan perut

Penggunaan otot bantu nafas: Tidak ada Ada: Retraksi dada/ Cuping hidung

Frekuensi nafas: ............................... kali/menit.

Masalah Keperawatan: Pola nafas tidak efektif

Gangguan pertukaran gas

C. ​Circulation

Akral : Hangat Dingin Pucat: Ya/ Tidak

Cianosis : Tidak Ya Pengisian kapiler: <2 detik/ >2 detik

Tekanan darah: .............../............... mmHg

Nadi : Teraba: ............ kali/menit Tidak teraba

Kelembapan kulit: Lembap Kering

Turgor kulit : Normal Kurang

Perdarahan : Tidak Ya: .................. cc, Lokasi perdarahan: ................................................................

Adanya riwayat kehilangan cairan dalam jumlah besar: Diare/ Muntah/ Luka bakar/ Perdarahan

Luas luka bakar: ............................... %, Grade: ............., Produksi urine: ....................... cc

Resiko dekubitus: Tidak Ya, lakukan pemeriksaan ​Norton Scale​, total skor: ....................................................

Masalah Keperawatan: Gangguan perfusi jaringan perifer

Gangguan keseimbangan cairan dan elektrolit

Resiko syok hipovolemik

D. ​Disability

Tingkat kesadaran : Komposmetis/ Apatis/ Delirium/ Somnolen/ Sopor/ Koma

Ukuran dan reaksi pupil: Miosis Midriasis, diameter: 1 mm/ 2 mm/ 3 mm/ 4 mm

GCS : E ....... M ....... V ....... Total: ......

Respon cahaya : + / -

Penilaian ekstremitas : Sensorik : Ya Tidak

Motorik : Ya Tidak

Masalah Keperawatan: Ketidakefektifan perfusi jaringan cerebral

Intoleran
aktivitas

Gangguan komunikasi
verbal
 Resiko
jatuh

E. ​Exposure

Adanya luka : Tidak Ya, Lokasi luka: ..................................................................................................

Pengkajian nyeri : ​Provoke/​ penyebab : ..........................................................................................................

Quality/​ kualitas : ..........................................................................................................

Region​/ area : ..........................................................................................................

Scale/​ skala : ..........................................................................................................

Time​/ waktu munculnya : .......................................................................................................... Suhu :

O​
.................... ​ C

Masalah Keperawatan: Nyeri

Hiperterm
i

Hipoterm
i
PENGKAJIAN KEPERAWATAN SEKUNDER Jam: ...........................

F. ​Full set of Vital Sign

Nadi : ............................ kali/menit

Frekuensi Nafas : ............................ kali/menit

Tekanan Darah : ............................ mmHg Suhu :

............................ O​
​ C

G. ​Head to Toe

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H. ​History

Allergies :​ .....................................................................................

Medications ​: .....................................................................................

Previous medical/surgical history​: ...........................................................

Last meal :​ .....................................................................................

Events ​: .....................................................................................

PEMERIKSAAN
PENUNJANG:

(Jika Tersedia, Lampirkan Data Pemeriksaan Pemeriksaan Penunjang) E

​ KG : YA
----------------------------------------------------- Tidak

Laboratorium : YA ----------------------------------------------------- Tidak

GDA : YA ----------------------------------------------------- Tidak

Radiologi : YA ----------------------------------------------------- Tidak

Masalah Keperawatan lainnya: ..........................................................................................................................................

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ANALISA DATA

Data Etiologi Masalah Keperawatan

 ........................................ Jam ...............

Perawat
__________________________________________

(TTD & Nama Terang)

PRIORITAS MASALAH
KEPERAWATAN

No Masalah Keperawatan Waktu Ditemukan

 ........................................ Jam ...............

Perawa
t

_________________________________________
_

(TTD & Nama Terang)

IMPLEMENTASI DAN EVALUASI

Masalah Keperawata Implementasi ​Evaluasi

........................................ Jam ...............

Perawat

__________________________________________

(TTD & Nama Terang