FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT

A. PENGKAJIAN

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

Nama : Jenis Kelamin : L/P Umur :

Agama : Status Perkawinan : Pendidikan :
Pekerjaan : Sumber informasi : Alamat :

TRIAGE Merah Kuning Hijau Hitam

PRIMARY SURVEY

GENERAL IMPRESSION
Keluhan Utama :

Mekanisme Cedera :

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...
AIRWAY
Jalan Nafas :  Paten  Tidak Paten
Obstruksi :  Lidah  Cairan  Benda Asing
Suara Nafas : Snoring Gurgling Stridor N/A
Keluhan Lain: ... ...

BREATHING

Gerakan dada:  Simetris  Asimetris

Irama Nafas :  Cepat  Dangkal  Normal
Pola Nafas :  Teratur  Tidak Teratur
Retraksi otot dada :  Ada  Tidak ada
Sesak Nafas :  Ada  Tidak ada
Frekuensi Nafas : ....................
Keluhan Lain : ....................

CIRCULATION
Nadi :  Teraba  Tidak teraba
Jumlah : x/menit
Sianosis :  Ya  Tidak
CRT :  < 2 detik  > 2 detik
Perdarahan :  Ya  Tidak ada Jumlah : .............. CC
Keluhan Lain: ....................
 DISABILITY

Respon : Alert  Verbal  Pain  Unrespon

Kesadaran :  CM  Delirium  Somnolen  ... ...
GCS :  Eye ...  Verbal ...  Motorik ...
PRIMARY SURVEY

Jumlah GCS :
Pupil :  Isokor  Unisokor  Pinpoint  Medriasis
Refleks Cahaya:  Ada  Tidak Ada
Lateralisasi :  Ada  Tidak Ada
Keluhan Lain : … …

EXPOSURE
Deformitas :  Ya  Tidak
Contusio :  Ya  Tidak
Abrasi :  Ya  Tidak
Penetrasi :  Ya  Tidak
Burn :  Ya  Tidak
Laserasi :  Ya  Tidak
Swelling :  Ya  Tidak

Keluhan Lain: ....................

SECONDARY SURVEY

ANAMNESA

Riwayat Penyakit Saat Ini : ....................

Riwayat Penyakit Sebelumnya : ....................

Sign and Symptom :

Alergi :

Medikasi :

Past Medical History :

Last Meal/ Makan Minum Terakhir :

Event/ Peristiwa Penyebab :

Tanda-tanda Vital :
 BP : mm/Hg N: x/menit S: RR : x/menit

Keluhan Nyeri (PQRST)

PEMERIKSAAN FISIK
Kepala dan Leher:
Inspeksi ... ...
Palpasi ... ...
Dada:
Inspeksi ... ...
Palpasi ... ...
Perkusi ... ...
SECONDARY SURVEY

Auskultasi ... ...

Abdomen:
Inspeksi ... ...
Palpasi ... ...
Perkusi ... ...
Auskultasi ... ...
Pelvis:
Inspeksi ... ...
Palpasi ... ...
Ektremitas Atas/Bawah:
Inspeksi ... ...
Palpasi ... ...
Punggung :
Inspeksi ... ...
Palpasi ... ...
Neurologis :

PEMERIKSAAN PENUNJANG
1. Pemerikasaan Lab

2. Pemeriksaan Diagnostik
 RONTGEN  CT-SCAN  USG  EKG
 ENDOSKOPI  Lain-lain, ... ...
Hasil :
 Tanggal Pengkajian : TANDA TANGAN PENGKAJI:
Jam :
Keterangan : NAMA TERANG :
B. ANALISA DATA
NO DATA MASALAH
DS DO
KEPERAWATAN

C. DIAGNOSA KEPERAWATAN

D. RENCANA KEPERAWATAN
NO DIAGNOSA TUJUAN INTERVENSI RASIONAL
KEPERAWATAN

E. TINDAKAN KEPERAWATAN
NO DIAGNOSA TINDAKAN EVALUASI
KEPERAWATAN

F. EVALUASI KEPERAWATAN
NO DIAGNOSA KEPERAWATAN EVALUASI
 Panduan Pengumpulan Data

PROGRAM ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN BALI
KEPERAWATAN GAWAT DARURAT
UNIT RAWAT INTENSIVE

Nama Mahasiswa : kelompok 2

Kasus : Pasien ICU

PENGKAJIAN Nama : NY. N Penanggung jawab :………………………

KEPERAWATAN Umur : …50………………Thn Jenis Kelamin : P Umur : …………..Thn
Agama : Hindu Islam Kristen Budha ………. Jenis Kelamin : L / P
Pendidikan : SMP Pekerjaan : Pedagang…………… Alamat : ………………………………….....
Alamat : Denpasar ………………………………………………
Perkawinan : Kawin ………………………………………………
Telp : ……………………………………….
Jam : ………………………………………..

Keluhan Utama MRS:

Penurunan kesadaran

Keluhan Utama saat pengkajian:

Tidak dapat dikaji karena pasien tidak sadar

Riwayat penyakit saat ini :

2 jam sebelum masuk Rumah sakit pasien tiba- tiba tidak sadar tidak bisa dibangunkan dari tempat tidur dan
mengorok kemudian pasien dibawa ke UGD sebuah rumah sakit setelah pasien mendapat pertolongan
pertama pasien masih belum sadar kemudian pasien di konsulkan ke dr spesialis saraf dan di putuskan untuk
di rawat di ruang ICU untuk perawatan intensif .
GCS E1M2Vterpasang ET, terpasang ventilator dengan mode SIM V,FiO2 70 %, PEEP+5, VT 487, RR =
38x/menit. Vital Sign TD 140/90 mmhg, Heart rate 120x/menit, suhu 38,5 0C dan SaO2 100% kondisi pupil
keduamya miosis, reflek cahaya +/_ , ada akumulasi secret di mulut dan diselang ET, tidak terpasang OPA
dan lidah tidak turun, terdapat retraksi otot interkosta dan terdengan ronchi basah di basal paru kanan. CRT<
3 detik. Di ICU klien sudah mendapat obat citicoline 500 mg/12 jam
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
............................
Riwayat alergi :
Pasien tidak mempunyai riwayat alergi obat ataupun alergi
makanan..................................................................................................................................................................
................................................................................................................................................................................
................................................................................................................................................................................
................................................................................

Riwayat pengobatan :
pasien tidak pernah melakukan pemeriksaan rutin di fasilitas kesehatan hanya menggunakan obat- obatan
Herbal bila
sakit.......................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
..............................................................................................

Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga :

Pasien mempunyai riwayat hipertensi sejak 1 tahun yang lalu dan orang tua pasien juga mempunya sakit
hipertensi dan sudah meninggal karena
stroke.....................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
..................................................................................................................................................................................................................
.............................................................................................................................................................................................................

PENGKAJIAN DIAGNOSA TINDAKAN

KEPERAWATAN KEPERAWATAN KEPERAWATAN
BREATHING
Airways

Snoring Stridor/crowing
Gurgling Tidak ada
Wheezing Tanda Fraktur Cervikal (ada/tidak ada)
Lain-lain (………………………………………)

Breating (Pola Nafas)

Laju Pernafasan
Dispnea Tachipneu Bradipneu
Orthponeu Apneu Lain-lain (………………)
 RR : 38 / menit
Irama Pernafasan
Teratur Tak TeraturLain-lain (………………)

PengembanganParu
Simetris Asimetris Lain-lain (………………)
Flail Chest

Bising pernafasan (auskultasi)

Tidak ada Vesikular Lain-lain (………………)

Perkusi pernafasan
Sonor Hipersonor Pekak
Lain-lain (………………)

Penggunaan ototBantu napas

Bahu diangkat Retraksi dada M. Sternocleidomastoideus
Cuping Hidung Pernafasan perut Lain-lain (………………)

Oksigenasi
Akral dingin Pucat Sianosis

Lain-lain
(………………………...........................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
...............................................................................................................................)

BLOOD
Perdarahan
Lokasi : …
Jumlah :…

Pulsasi
Kuat Lemah Tidak teraba

Laju nadi
Takikardia Bradikardia Normal

Ket : …. x/mnt

Tekanan darah
Hipotensi Hipertensi Tidak terukur
Normal
TD : … mmHg

Nyeri dada
Ada Tidak ada
Lokasi :…
Karakteristik : …
Jumlah :…

Perfusi
Akral dingin Pusing/nyeri kepala Kesemutan
 Tremor Pucat Edema
Pengisian kapiler < 3 detik > 3 detik

Produksi Urine
AnuriaOliguria
Normal
Urine output : … CC/jam

BRAIN
Kesadaran
Compos mentis Samnolen Koma
Delirium Apatis

GCS
Eye .... Verbal ... Motorik …

PupilIsokor Anisokor Medriasis

Pinpoint

Reflek Cahaya Ada Tidak ada

Reflek Fisiologis Patella Lain-lain ...

Reflek Patologis Babinzky Kernig

Lain-lain ...

Bicara Koheren Inkoheren

Tidur Malam......jam/hari Siang....jam/hari

Ansietas Ada Tidak ada

Lain-lain : (............................................................................................................)
BLADDER

Nyeri pinggang Ada Tidak ada

BAK Lancar Inkontenensia

Anuri

Nyeri BAK Ada Tidak ada

Frekuensi BAK.... warna...Darah Ada Tidak ada

Kateter Ada Tidak ada

Jumlah urine output.... CC/....jam

BOWEL

TB : ... CM BB: ... Kg

Nafsu makan Baik Menurun

Keluhan Mual Muntah
 Sulit menelan

Makan : Frekuensi... x/hari Jumlah :... porsi

Minum : Jumlah ... cc/24 jam

Meteorismus Ada Tidak ada

Acites Ada Tidak ada

BAB Teratur Tidak teratur

Frekuensi BAB : ... x/hari Konsistensi... Warna : darah/lendir

BU (peristaltik usus) .... x/mnt

Lain-lain ...

BONE

Nyeri Ada Tidak ada

Problem : ...

Regio : ...

Timing : ...

Kekuatan otot : ...

Kualitas/kuantitas : ...

Skala : ...

Deformitas Ada Tidak ada Lokasi...

Contusio Ada Tidak ada Lokasi...

Abrasi Ada Tidak ada Lokasi...

Penetrasi Ada Tidak ada Lokasi...

Laserasi Ada Tidak ada Lokasi...

Edema Ada Tidak ada Lokasi...

Luka bakar Ada Tidak ada Lokasi...

Grade : ... %
Jika ada luka/vulnus, kaji :

Luas luka : ...

Warna dasar luka :...

Kedalaman : ...

Aktivas dan latihan : 0 1 2 3 4

Makan/minum : 0 1 2 3 4

Mandi : 0 1 2 3 4

Toileting : 0 1 2 3 4

Berpakaian : 0 1 2 3 4

Mobilisasi : 0 1 2 3 4

Berpindah : 0 1 2 3 4

Ambulasi : 0 1 2 3 4

Lain-lain : ....

Keterangan :

0 : Mandiri
1 : Alat bantu
2 : Dibantu orang lain
3 : Dibantu orang lain dan alat
4 : Tergantung total

Keracunan (intoksikasi)

Makanan Gigitan binatang Zat kimia

Gas Obat – obatan Lain-lain (………………)

 Pengkajian Sekunder

Riwayat Kesehatan Sekarang :

.......Saat ini pasien sedang mengalami penurunan kesadaran dirawat di ICU dengan menggunakan Ventilator GCS
E1V1M1...........................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..
.....................................................................................................................................................................................................

Riwayat Kesehatan Lalu :

........pasien mempunyai riwayat hipertensi sejak satu tahun yang lalu tetapi tidak pernah
kontrol...............................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
.........................................................................................................................................................................................
Riwayat Kesehatan Keluarga :
Orang tua pasien mempunyai riwayat hipertensi dan meninggal karena mengalami
stroke.................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
.................................................................................................................................................................................................

Pengkajian Head to Toe

Kepala dan wajah

Bentuk Mesochepal, tidak ada luka dan jejas, rambut hitam, tidak ada edema.
Leher
Tidak terdapat pembesaran kelenjar limfe dan tiroid, tidak terjadi kaku kuduk

Thorak
a. Jantung
Inspeksi : Ictus cordis tidak tampak
Palpasi : ictus cordis tidak teraba
Perkusi : Pekak
Auskultasi : Bunyi jantuk I- II normal,tidak ada bunyi jantung tambahan
b. Paru- Paru
Inspeksi : Paru kanan dan kiria asimetris, terdapat retraksi intercostal,tidak ada ada menggunakan
otot bantu nafas. RR 38x/menit.
Palpasi : Tidak ada krepitasi
Perkusi : sonor dideluruh lapang paru
Auskultasi : terdengar suara ronchi basah di basal paru kanan

Abdomen dan pinggang

Inspeksi : Datar
Auskultasi : Bising usus 13x/menit
Perkusi : Timpani
Palpasi : Tidak ada distensi abdomen

Pelvis dan Perineum

Pelvis Tidak ada krepitasi, Perinium tidak ada odem, tidak ada jejas / perdarahan

Ekstremitas
Tidak ada luka, tidak ada jejas, Derpomitas tidak ada, edema tidak ada. Kekuatan otot 1/1/1/1.

Integumen
Elastisitas kulit baik, tidak ada dekubitus
 Pemeriksaan Penunjang & Terapi Medis

Radiologi Laboratorium Darah Pemeriksaan Lain Terapi Medis

Rencana CT scan dan AGD citicoline 500 mg/12 jam
Thorak foto PH= 6.9
Belum bias dilakukan PCO2 = 43mmHg
karena kondisi pasien HCO3= 29 mEq/L
belum stabil Darah lengkap
WBC = 10.000
HB = 9,0
PLT = 250.000
Hematokrit 37 %
Eritrosit 3,5 juta

Masalah Keperawatan :
1. Ketidakefektifan bersihan jalan nafas
2. Gangguan perfusi jaringan cerebral
3. Gangguan pertukaran gas……………………………………………………….
4. ……………………………………………………….
5. ……………………………………………………….
6. ……………………………………………………….
7. ……………………………………………………….
8. ……………………………………………………….
9. ……………………………………………………….
10. ……………………………………………………….
11. ……………………………………………………….