KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN

SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN PANGKALPINANG
Komplek Perkantoran dan Pemukiman Terpadu Pemprov Kepulauan Bangka Belitung
Jalan Telaga Biru I Desa Padang Baru Kecamtan Pangkalan Baru Kabupaten Bangka Tengah
Telepon & Fax : (0717) 422014, Email : Poltekkespapinka@gmail.com

PETUNJUK PENULISAN RESUME DENGAN

FORMAT PENGKAJIAN GAWAT DARURAT

Pengkajian dilakukan pada hari............................tanggal ……......................................., jam ................WIB

di .........................................................

A. PENGKAJIAN
1. Biodata
a. Identitas Klien
Nama : ....................................................................
Umur (TL) : ....................................................................
Jenis Kelamin : ....................................................................
Agama : ....................................................................
Pendidikan : ....................................................................
Pekerjaan : ....................................................................
Status Perkawinan : ....................................................................
Suku Bangsa : ....................................................................
Alamat : ....................................................................
No. RM : ....................................................................
Diagnosa Medis : ....................................................................
Jam MRS : .....................................................................

b. Penganggung jawab
Nama : ....................................................................
Umur (TL) : ....................................................................
Jenis Kelamin : ....................................................................
Hub. Dgn klien : ....................................................................
Alamat : ....................................................................

2. Pengkajian Primer
a. Airway
(Pemeriksaan jalan napas pasien ada obstruksi atau tidak, suara napas yang
terdengar dan keluhan lainnya)
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 b. Breathing
1) Inspeksi (bentuk dada, irama napas, frekuensi napas, pola napas, kedalaman
napas, bantuan napas, retraksi dada, otot dada, sesak napas, reflek batuk, ada
sputum/ tidak, warna dan konsistensi sputum, dll)
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2) Palpasi (fremitus, pengembangan dada kanan/kiri)
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3) Perkusi (ada massa atau tidak)
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4) Auskultasi ( suara napas, normal/tidak)
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c. Circulation
(Pemeriksaan TD, nadi, irama dan denyut nadi, CRT, ekstremitas hangat/dingin,
warna kulit, adanya sianosis, nyeri dada, karakteristik nyeri dada, perdarahan/tdk)
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d. Disability
(Pemeriksaan Respon (AVPU), kesadaran, GCS, pupil, refleks cahaya, refleks gerakan)
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e. Exposure/Event/Environment
(Pemeriksaan seluruh bagian tubuh terhadap adanya dan lokasi deformitas/tdk,
contusio/tdk, abrasi/tdk, penetrasi/tdk, laserasi/tdk, edema/tdk, dengan pencegahan
hipotermi, penyebab kejadian )
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f. Folley Catheter
g. Gastric Tube Jika di perlukan sesuai dengan kondisi pasien
h. Heart Monitoring

3. Pengkajian Sekunder
a. Keluhan Utama
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b. Riwayat Kesehatan Sekarang

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c. AMPLE
Alergi :.......................................................................................
Medikasi :.......................................................................................
Past medikal history :.......................................................................................
Last meal :.......................................................................................
Event/peristiwa penyebab :...................................................................................

4. Pemeriksaan Fisik
a. Head To Toe
1) Kepala dan Leher
a) Inspeksi
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b) Palpasi
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2) Pemeriksaan Thorax
a) Inspeksi
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b) Palpasi
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c) Perkusi
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d) Auskultasi
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3) Pemeriksaan Abdomen
a) Inspeksi
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b) Auskultasi
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c) Perkusi
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d) Palpasi
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4) Pemeriksaan ekstermitas
a) Inspeksi
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b) Palpasi
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5. Pemeriksaan penunjang
a. Hasil laboratorium
Tabel 1. Hasil laboratorium pada……………..
NO JENIS PEMERIKSAAN HASIL NILAI NORMAL INTERPRETASI
 b. Pemeriksaan penunjang lain
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6. Tindakan kolaborasi medis

a. ..............................................................................................................
b. ..............................................................................................................
c. ..............................................................................................................
d. .............................................................................................................................
e. .............................................................................................................................

7. Analisa data

No Data Fokus Etiologi Masalah

keperawatan

1. DS:

DO:

B. Diagnosa Keperawatan

1. ..........................................................................................................
2. ..........................................................................................................
3. ..........................................................................................................

C. Intervensi Keperawatan

No Diagnosa Rencana Keperawatan

NOC NIC
1.

D. Implementasi Keperawatan
 No Waktu Tindakan Diagnosa Paraf dan Nama
(hari, tgl, jam )
1. Tindakan NIC 1 :
Respon.............

E. Evaluasi Keperawatan

No. Hari /Tanggal/ jam Diagnosa Keperawatan Evaluasi

1. S:

O:

A:

P:

Tanda Tangan Preceptor Tanda Tangan Mahasiswa

(………………………) (………………………………)