BAGIAN KGD FORMAT PENGKAJIAN KEPERAWATAN KRITIS

STIKes WN
I. Identitas Mahasiswa
Nama MHS :
NIM :
Kelompok :
Tgl Praktek :

II. Identitas Klien

Nama : ............................................ Umur : ..............................
No. MR : ............................................ Jenis Kelamin : ..............................
Tanggal : ............................................ Hari rawat ke : ..............................
Agama : ............................................ Status : ..............................
Alergi : ............................................ Berat badan : ..............................
Alamat Rumah : .........................................................................................................
Diagosa Medis : .........................................................................................................

III. Alasan dirawat di ICU

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IV. Pengkajian Fisik Dan Pengkajian Umum

Kardiovaskuler Muskuloskeletal

Dx. Kep: Dx. Kep:

Pernafasan Genitourinaria

Dx. Kep: Dx. Kep:

Neurologis dan Sensori Integumen

Dx. Kep: Dx. Kep:

Gastrointestinal Endokrin
 Dx. Kep: Dx. Kep:

Nutrisi Psikososial

Dx. Kep: Dx. Kep:

Cairan Istirahat Tidur

Dx. Kep: Dx. Kep:

V. Monitoring Tiap Jam

6 7 8 9 10 11 12 13 14
H 40
E
M
O
D 39
I
N
A
M
I
K 38

37

36

Kesadaran 35
Irama EKG
Nyeri
CVP

Resp Tipe Vent

PEEP/
CPAP
RR
TV
 Neuro Mata
Ukuran
Reaksi
Kaki
Tangan
GCS
Input Line 1

Line 2

Line 3

Line 4

Enteral

Total
Output NGT
Urine
BAB
Drain
Total

VI. Terapi/Program Medis

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VII. Hasil Uji Diagnostik
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Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan :

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 BAGIAN KGD FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT
STIKes WN
I. Identitas Mahasiswa
Nama MHS :
NIM :
Kelompok :
Tgl Praktek :

II. IDENTITAS KLIEN

NAMA KLIEN :
USIA/TGL LAHIR :
JENIS KELAMIN :
TANGGAL MASUK :
NO REGISTER :
DIAGNOSA MEDIK :

TRIAGE: P1 P2 P3 P4

III. KELUHAN UTAMA ALASAN MASUK RS

P : ………………………………………………………………………………………………..
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Q : ………………………………………………………………………………………………..
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R : ………………………………………………………………………………………………..
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S : ………………………………………………………………………………………………..
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T : ………………………………………………………………………………………………..
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IV. PENGKAJIAN PRIMER

AIRWAY
SUMBATAN:
Jalan Nafas :  Paten  Tidak Paten
Obstruksi :  Lidah  Cairan  Benda Asing  T/A
Suara Nafas : Snoring/mdgkr Gurgling/brdenguk Stridor /berisik sep angin T/A
Perhatian : Cedera servikal

BREATHING
Sesak, dengan :
Aktifitas ....................................................................................
Tanpa aktifitas .........................................................................
Nafas cuping hidung ...............................................................
Menggunakan otot tambahan .................................................
Frekuensi
Irama:
Teratur .....................................................................................
Tidak teratur ............................................................................
Kedalaman
Dalam ..................................................................................
Dangkal ................................................................................
Cepat....................................................................................
Batuk:
Produktif ...............................................................................
Non produktif ........................................................................
 Bunyi nafas tambahan:
Ronkhi ..................................................................................
Crackles/celah,retak ............................................................
Wheezing/Mencuit2 ..............................................................

CIRCULATION
Kesadaran : .............................................................................
Sirkulasi perifer : .......................................................................
Nadi : ........................
Irama :........................
Teratur /Tidak teratur : .........................................................
Denyut:
Lemah ..................................................................................
Kuat .....................................................................................
Tidak kuat .............
Tekanan darah :.........
Ekstremitas : ..............
Hangat ..................
Dingin ..................
Warna kulit :
Cyanosis ..............
Pucat ....................
Kemerahan ...........

DISABILITY
Pemeriksaan neurologis singkat
Respon:
Alert/perhatian ......................................................................
Voice respons/respon terhadap suara .................................
Pain respons/respon terhadap nyeri .....................................
Unresponsive/tidak berespon ...............................................
Reaksi pupil ..........................................................................

EKSPOSURE/ENVIRONMENT/EVENT
Deformitas :  Ya  Tidak
Contusio :  Ya  Tidak
Abrasi :  Ya  Tidak
Penetrasi :  Ya  Tidak
Laserasi :  Ya  Tidak
Edema :  Ya  Tidak
Keluhan Lain:
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V. PENGKAJIAN SEKUNDER
Riwayat kesehatan sekarang ....................................................
Riwayat kesehatan keluarga ....................................................
Anamnesa singkat (AMPLE) ......................................................
Allergies.............................
Medikasi ............................
Nyeri ..................................
Terakhir kali makan ...........
Event of injury/penyebab injury..........

Pemeriksaan head to toe

- Kepala
Rambut :
- Mata :

- Telinga :
 - Hidung :

- Mulut :

- Leher
Deviasi/simetns, cedera servikal ..........................................
Kelenjar tiroid .......................................................................
Kelenjar limfe .......................................................................
Trakea ..................................................................................
JVP.......................................................................................

- Dada
I :

P :

P :

A :

- Abdomen :
I :

A :

P :

P :

- Ekstermitas/musculoskeletal
Rentang gerak.................................................................
Kekuatan otot ..................................................................
Deformitas.......................................................................
Kontraktur .......................................................................
Edema ............................................................................
Nyeri................................................................................
Krepitasi ..........................................................................

- Kulit/integumen:
Turgor:
Baik .................
Buruk ..............
Sedang ...........
Mukosa:
Lembab ...........
Kering..............
Kulit:
Bintik merah ...
Lesi .................
Suhu .....................

VI. PEMERIKSAAN PENUNJANG

Pemeriksaan Radiologi :

Pemeriksaan Lab darah :

Pemeriksaan Penunjang lainnya :

VII. TERAPI MEDIS

Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan :

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