FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT

A. PENGKAJIAN

ID No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...
E
Nama : Jenis Kelamin : L/P Umur :
N
TI Agama : Status Perkawinan : Pendidikan :
T
Pekerjaan : Sumber informasi : Alamat :
A
S
TRIAGE Merah Kuning Hijau Hitam

P GENERAL IMPRESSION
Keluhan Utama :
R
Mekanisme Cedera :
I
M
A Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...
AIRWAY
R Jalan Nafas :  Paten  Tidak Paten

Y Obstruksi :  Lidah  Cairan  Benda Asing

Suara Nafas : Snoring Gurgling StridorN/A
Keluhan Lain: ... ...
S
U BREATHING
R
V Gerakan dada:  Simetris  Asimetris

E Irama Nafas :  Cepat  Dangkal  Normal

Y 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 adaJumlah : .............. CC
Keluhan Lain: ....................
 DISABILITY
Respon : Alert  Verbal  Pain  Unrespon
Kesadaran :  CM  Delirium  Somnolen  ... ...
PR GCS :  Eye ...  Verbal ...  Motorik ...

IM Jumlah GCS :
Pupil :  Isokor  Unisokor  Pinpoint  Medriasis
AR Refleks Cahaya:  Ada  Tidak Ada
Y Lateralisasi :  Ada  Tidak Ada
SU Keluhan Lain : … …
RV
EY EXPOSURE
Deformitas :  Ya Tidak
Contusio :  Ya Tidak
Abrasi :  Ya Tidak
Penetrasi : Ya Tidak
Burn: Ya Tidak
Laserasi : Ya Tidak
Swelling : Ya Tidak

KeluhanLain: ....................

S ANAMNESA

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

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

O
N Sign and Symptom :

D Alergi :
A
R Medikasi :

Y
Past Medical History :

S Last Meal/ Makan Minum Terakhir:

U
R 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 ... ...
SE Perkusi ... ...
C Auskultasi ... ...
O Abdomen:

ND Inspeksi ... ...

Palpasi ... ...
AR
V Perkusi ... ...
YE Auskultasi ... ...
SU
Y Pelvis:
RV Inspeksi ... ...

EY 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 :
A. ANALISA DATA
NO DATA MASALAH
DS DO
KEPERAWATAN

B. DIAGNOSA KEPERAWATAN

C. RENCANA KEPERAWATAN
NO DIAGNOSA TUJUAN INTERVENSI RASIONAL
KEPERAWATAN

D. TINDAKAN KEPERAWATAN
NO DIAGNOSA TINDAKAN EVALUASI
KEPERAWATAN
E. EVALUASI KEPERAWATAN
NO DIAGNOSA KEPERAWATAN EVALUASI

PanduanPengumpulan Data

PROGRAM ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN BALI
 KEPERAWATAN GAWAT DARURAT
UNIT RAWAT INTENSIVE

NamaMahasiswa :
NIM :

PENGKAJIAN Nama : ………….............................................................. Penanggung jawab :………………………

KEPERAWATAN Umur : …………………. Thn Jenis Kelamin : L/ P Umur : …………..Thn
Agama : Hindu Islam Kristen Budha ………. Jenis Kelamin : L / P
Pendidikan : ………………… Pekerjaan : …………… Alamat : ………………………………….....
Alamat : …………………………………………….. ………………………………………………
…………………………………………….. ………………………………………………
Perkawinan : Kawin / Belum Kawin / Lain-lain Telp : ……………………………………….
Jam : ………………………………………..

Keluhan Utama MRS:

Keluhan Utama saat pengkajian:

Riwayat penyakit saat ini :

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

Riwayat alergi :
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.............................................................................................................................................................................................

Riwayat pengobatan :
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
...........................................................................................................................................................................................................

Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga :

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

PENGKAJIAN DIAGNOSA TINDAKAN

KEPERAWATAN KEPERAWATAN KEPERAWATAN
BREATHING
Airways

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

Breating (Pola Nafas)

Laju Pernafasan
Dispnea Tachipneu Bradipneu
Orthponeu Apneu Lain-lain (………………)
RR : …..
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 perutLain-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 < 2 detik > 2 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 :

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

Riwayat Kesehatan Lalu :

..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
.......................................................................................................................................................................................
Riwayat Kesehatan Keluarga :
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
..........................................................................................................................................................................................................
.......................................................................................................................................................................................

Pengkajian Head to Toe

Kepala dan wajah

Leher

Thorak

Abdomen dan pinggang

Pelvis dan Perineum

Ekstremitas

Integumen
 Pemeriksaan Penunjang & Terapi Medis

Radiologi Laboratorium Darah Pemeriksaan Lain Terapi Medis

Masalah Keperawatan :
1. ……………………………………………………….
2. ……………………………………………………….
3. ……………………………………………………….
4. ……………………………………………………….
5. ……………………………………………………….
6. ……………………………………………………….
7. ……………………………………………………….
8. ……………………………………………………….
9. ……………………………………………………….