AKADEMI KEPERAWATAN

PEMERINTAH KABUPATEN KONAWE

Jl. Sultan Hasanuddin No. 111, Kel. Lalosabila, Kec. Wawotobi Telp (0408) 21459

1. PENGKAJIAN KEPERAWATAN GAWAT DARURAT DAN DI RUANG ICU

Tgl/ jam : ………………………………… No. RM :……………………………..
Triage : P1/P2/P3 Diagnosis Medis: ……………………………..
Transportasi : ambulan/mobil pribadi/lain-lain:…………………………...........................................
IDENTITAS

Nama :......................................................... Jenis Kelamin :.................................................

Umur : ........................................................
Agama : ......................................................
Pendidikan : ...............................................
Pekerjaan : ..................................................
Suku / bangsa : ...........................................
 Paten
AIRWAY
Alamat : ...........................................................
Status Perkawinan : .........................................
Sumber Informasi : ..........................................
Hubungan : ......................................................
Keluhan Utama : ..............................................
 Tidak Paten

Jalan nafas :
Obstruksi :  Lidah  Cairan  Benda Asing  Tidak ada
 Muntahan  Darah  Oedema
Suara nafas :  Snoring  Gurgling  Stridor  Tidak ada

Keluhan lain : ............................................................................................................................

Masalah keperawatan : ...............................................................................................................

 
BREATHNG

Nafas Spontan Tidak Spontan

Gerakan dinding dada  Simetris  Asimetris
Irama nafas  Cepat  Dangkal  Normal  Ada
Pola nafas  Teratur  Tidak Teratur
Jenis  Dispneu  Kusmaul  Cyene Stoke  Lain..
Suara nafas  Vesikuler  Stridor  Wheezing  Ronchi
Cuping hidung  Ada  Tidak ada
Retraksi otot bantu nafas  Ada  Tidak ada
Pernafasan  Dada  Perut RR: .........x/mnt

Keluhan lain : .............................................................................................................................

Masalah keperawatan : ...............................................................................................................

 Teraba  Tidak Teraba  N: .........x/mnt

CIRCULATION

Nadi
Tekanan Darah ...................mmHg 
Pucat  Ya  Tidak 
Sianosis  Ya  Tidak 
CRT  < 2 dtk  > 2 dtk
Akral  Hangat  Dingin
Perdarahan  Ada  Tidak ada 
 Lokasi .................................. 
 Jumlah ..............................cc 
Turgor  Elastis  Lambat
Diaphoresis  Ya  Tidak
Riwayat kehilangan cairan berlebih  Diare  Muntah  Luka Bakar
Keluhan lain :..............................................................................................................................
Masalah keperawatan : ..............................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No. 111, Kel. Lalosabila, Kec. Wawotobi Telp (0408) 21459

  Delirium  Somnolen  Apatis  Koma

DISABILITY

Kesadaran Composmentis
GCS  Eye  Verbal  Motorik
Pupil  Isokor  Unisokor  Pinpoint  Medriasis
Refleks Cahaya  Ada  Tidak Ada
Refleks Fisiologis  Patela (+/-) ...................
Refleks Patologis  Babinzky (+/-) ...................
 Kernig (+/-) ...................
 Lain.................
Kekuatan Otot

Keluhan lain :..............................................................................................................................

Masalah keperawatan : ...............................................................................................................
EXPOSURE

Deformitas  Ya  Tidak  Lokasi ...............................

Contusio  Ya  Tidak  Lokasi ...............................
Abrasi  Ya  Tidak  Lokasi ...............................
Penetrasi  Ya  Tidak  Lokasi ...............................
Laserasi  Ya  Tidak  Lokasi ...............................
Edema  Ya  Tidak  Lokasi ...............................
Luka Bakar  Ya  Tidak  Lokasi ...............................
 Jika terdapat Luka/ Grade .............%  Lokasi ...............................
vulnus, kaji:  Luas Luka ......................
 Warna Dasar Luka ......................
 Kedalaman Luka ......................

Lain-lain: ....................................................................................................................................
Masalah Keperawatan : ..............................................................................................................
....................................................................................................................................................
Monitoring jantung :  sinus bradikardi  sinus takikardi
FIV
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No. 111, Kel. Lalosabila, Kec. Wawotobi Telp (0408) 21459
E INTERVENTION

Saturasi oksigen : ............... %

Kateter urine :  ada  tidak ada
Pemasangan NGT :  Ada, warna cairan lambung :.................................
 Tidak
Terapi Medis:
....................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
................................................................................................................................................................................
Lain-lain: ....................................................................................................................................
Masalah keperawatan :................................................................................................................
Pemeriksaan Laboratorium:

:  Ada  Tidak Ada

GIV

Nyeri
Problem : .......................................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No. 111, Kel. Lalosabila, Kec. Wawotobi Telp (0408) 21459
E COMFORT

Qualitas/ quantitas : ...................................................................................................................

Regio : .......................................................................................................................................
Skala : ........................................................................................................................................
Timing : .....................................................................................................................................
Lain-lain : ..................................................................................................................................
Masalah keperawatan : ..............................................................................................................
....................................................................................................................................................
HISTORY

Keluhan utama :
....................................................................................................................................................
Mekanisme cidera (trauma) :
..................................................................................................................................................................................
......................................................................................................................
....................................................................................................................................................
Sign / tanda gejala :
..................................................................................................................................................................................
..................................................................................................................................................................................
........................................................................................
Alergi :
....................................................................................................................................................
Medication / pengobatan :
..................................................................................................................................................................................
......................................................................................................................
Post Medical History :
..................................................................................................................................................................................
......................................................................................................................
Last Oral Intake:
....................................................................................................................................................
Event Leading Injury:
..................................................................................................................................................................................
......................................................................................................................
HEAD TO TOEHEAD TO TOE

(fokus pemeriksaan pada daerah trauma / sesuai kasus nontrauma )

Kepala dan wajah :
..................................................................................................................................................................................
..................................................................................................................................................................................
........................................................................................
Leher :
..................................................................................................................................................................................
..................................................................................................................................................................................
........................................................................................
Dada :
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
..........................................................
Abdomen dan pinggang :
..................................................................................................................................................................................
..................................................................................................................................................................................
........................................................................................
Pelvis dan perineum :
..................................................................................................................................................................................
......................................................................................................................
Ekstremitas :
 Atas:
..................................................................................................................................................................................
..................................................................................................................................................................................
........................................................................................
 Bawah
................................................................................................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No. 111, Kel. Lalosabila, Kec. Wawotobi Telp (0408) 21459

................................................................................................................................................................................
......................................................................................
Masalah keperawatan :
..................................................................................................................................................................................
......................................................................................................................
:  Ada  Tidak
INSPECTION BACK/ POSTERIOR SURFACE

Jejas
....................................................................................................................................................
Deformitas :  Ada  Tidak
....................................................................................................................................................
Tenderness :  Ada  Tidak
....................................................................................................................................................
Crepitasi :  Ada  Tidak
....................................................................................................................................................
Laserasi :  Ada  Tidak
....................................................................................................................................................
Lain-lain:.....................................................................................................................................
Masalah keperawatan : ..............................................................................................................
....................................................................................................................................................

1. Klasifikasi Data

2. Analisa Data

3. Diagnosa Keperawatan

4. Rencana Asuhan Keperawatan

5. Implementasi

6. Evaluasi
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No. 111, Kel. Lalosabila, Kec. Wawotobi Telp (0408) 21459