YAYASAN DHARMA BHAKTI INDONESIA

UNIVERSITAS SARIPUTRA INDONESIA TOMOHON

FAKULTAS KEPERAWTAN
Jl. Kampus Unsrit Kakaskasen II Telp./fax : (0431)353244,Kontak Pos 101,Tomohon-Sulut

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

A. IDENTITAS KLIEN

Jenis Kelamin : Lk/ Pr

Nama Pasien :................................... Umur................................ No RM :.....................................

Nama Keluarga :...........................................

Agama :...........................................
Pekerjaan :...........................................
ALamat Kantor :.................................................................................Tlp.............................................
Alamat Rumah :....................................................................................................................................
.................................................................................Tlp.............................................
Diagnosa medik : .....................................
Datang Ke RS Tanggal :.......................................................................

Kendaraan : Ambulans 118 ; Mobil Pribadi Kendaraan Lain.............................................................

B. PENGKAJIAN

Keluhan Utama :...................................................................................................................................................................

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Riwayat penyakit : .................................................................................................................................................................

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 Pengkajian Keperawatan Masalah/ Diagnosa Tindakan Keperawatan
Keperawatan

A. Airway Aktual Resiko Membersikan Jalan Nafas

Bebas Gangguan Bersihan Jalan Memberikan Posisi Nyaman
Tidak bebas Nafas Tidak Efektif Fowler/ Semi Fowler
Pangkal Lidah Jatuh Mengajarkan Teknik Batuk
Sputum Aktual Resiko Efektif
Darah Jalan Napas Tidak Efektif Melakukan Pengisapan Lendir
Spasme Memasang Oro/ naso Faringeal
Benda Asing Airway
Suara Nafas Melakukan Auskultasi Paru
Normal secara Periodik
Stridor Memberikan Posisi Miring mantap
Tidak Ada Suara napas Jika pasien tidak sadar
Lain – lain ................................... Melakukan jaw thrust, chin lift
Lain –lain :..........................................
B. Breathing Aktual Resiko Mengawasi adanya perubahan
Pola Nafas : Gangguan Perfusi Jaringan warna kulit
Apneu Dyspnue Perifer Mengukur Tanda – tanda Vital
Bradipnue Takipnue Mengkaji kekuatan nadi perifer
Orthopnue Mengkaji tanda – tanda dehidrasi
Mengobservasi keseimbangan
Frekuensi Nafas :.............x/m
cairan
Bunyi Nafas : Meninggikan daerah yang cedera
Vesikuler Whezing jika tidak ada kontraindikasi
Stridor Ronchi Memberikan cairan peroral jika
memungkinkan
Irama Nafas
Mengobservasi tanda-tanda
Teratur
adanya kompartemen syndrom
Tidak Teratur
(nyeri lokal daerahcedera, pucat,
Penggunaan Otot Bantu nafas penurunan mobilitas, penurunan
Retraksi dada tekanan nadi, nyeri bertambah
Cuping Hidung saat digerakan, perubahan
sensori/ baal dan kesemutan.
Lain - Lain :
...........................................................
Jenis Pernapasan ...........................................................
Pernapasan dada
 Pernapasan Perut ..........................................................
...........................................................
Hasil AGD :
...........................................................
........................................................
...........................................................
.......................................................
....................................................... ...........................................................
......................................................
.......................................................
......................................................

Lain – lain :..................................

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C. Circulation Aktual Resiko Mengawasi adanya perubahan
Akral : Gangguan Perfusi Jaringan warna kulit
Hangat Dingin Perifer Mengukur tanda – tanda vital
Mengkaji kekuatan nadi perifer
Pucat : ya Tidak
Mengkaji tanda-tanda dehidrasi
Cianosis : Ya Tidak
Mengobservasi keseimbangan
Pengisian Kapiler : Cairan
Meninggikan bagian yang cidera
< 2 detik > 2 detik
Jika tidak ada kontraindikasi
Nadi : Memberikan cairan peroral jika
Teraba Memungkinkan
Mengobservasi tanda-tanda
Tidak Teraba
adanya kompartemen syndrom
Frekuensi :.....................x/m
(nyeri lokaldaerah cidera, pucat,
Tekanan Darah :............mmHg penurunan mobilitas, penurunan
tekanan nadi, nyeri bertambah
Perdarahan :
saat digerakan, perubahan
Ya Tidak
sensori/ baal dan kesemutan.
Jika Ya.................CC Lain - lain :.......................................
...........................................................
Lokasi Perdarahan:...................
.....................................................
Kelembaban Kulit :
Lembab Kering
Turgor
Normal Kurang
Lain – lain :................................
.......................................................
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Adanya Riwayat Kehilangan Cairan Aktual Resiko Mengkaji tanda- tanda dehidrasi
Dalam Jumlah besar : Volume Cairan Tubuh Kurang Mengukur tanda – tanda vital,
Diare Muntah Dari kebutuhan tingkat kesadaran
Luka Bakar Perdarahan Memberikan cairan peroral jika
masi memungkinkan hingga
Akral :
2000-2500 cc/hari
Hangat Dingin
Memberikan cairan melalui
Pucat : Ya Tidak
intavena
Cianosis : ya Tidak
Memonitor intake – output
Pengisian Kapiler :
cairan setiap jam : Pasang
< 2 detik > 2 detik
kateter dll.
Nadi : Teraba
Menyiapkan alat – alat untuk
Tidak Teraba
pemasangan CVP jika diperlukan
Tekanan darah :.................mmHg
Memonitor CVP dan perubahan
Perdarahan :
nilai elektrolit tubuh
Ya Tidak
Kolaborasi:
Jika Ya.................CC
Melakukan infus dengan jarum
Lokasi Perdarahan:...................
yang besar 2 line
.....................................................
Menyiapkan pemberian transfusi
Kelembaban Kulit :
darah jika penyebabnya
Lembab Kering
perdarahan, koloid jika darah
Turgor
trasfusi susah didapat.
Normal Kurang
Lain – lain:......................................
Luas Luka Bakar:............................%
Grade :...............................................
Lain – lain :..........................................

D. Disability Aktual Resiko Mengkaji Karakteristik Nyeri

Tingkat Kesadaran : Gangguan Perfusi Jaringan Mengukur tanda – tanda vital
Nilai GCS Dewasa: E M V Serabral Mengobservasi perubahan
Pada anak : A V P U tingkat kesadaran
Pupil : Normal Meninggikan kepala 15 - 30ºjika
Respon Cahaya +/- tidak ada kontra indikasi
Ukuran Pupil: Isokor Mengobservasi kecukupan cairan
An Isokor
Diameter O 1mm O 2mm Kolaborasi:
O 3mm O 4mm Pemberian Oksigen
Penilaian Ekstremitas Pemasangan Infus
Sensorik : Ya Tidak Monitor hasil AGD dan laporkan
 Motorik : Ya Tidak hasilnya
Kekuatan Otot/ Skala : Memberikan therapi sesuai
Lovetts indikasi
Lain – lain :.................................. Lain – lain:......................................

E. Exposure Nyeri Mengkaji karakteristik nyeri,

Adanya trauma pada gunakan pendekatan PQRST
daerah.......................................... Mengajarkan teknik relaksasi
. Membatasi aktifitas yang
Adanya Jejas/Luka pada meningkatkan intensitas nyeri
daerah ......................................... Kolaborasi untuk pemberian
- Ukuran Luas .................cm² therapi :
- Kedalaman Luka:..........cm² - Analgetik
Keluhan Nyeri : - Oksigen
- Daerah Nyeri :..................... - Infus
- Lama Nyeri :........................ - Perekaman EKG
- Jenis Nyeri :.........................
Lain-lain :................................................
Lain – lain :..........................................

F. Fahrenheit (Suhu Tubuh) Aktual Resiko Mengobservasi suhu tubuh, TTV,

Suhu :.................ºc Gangguan suhu Hyperthermia Kesadaran, saturasi Oksigen
Lamanya terpapar suhu Membuka pakaian (menjaga
panas/ dingin......................Jam privasi)
Riwayat Pemakain Obat Melakukan Penurunan suhu
Riwayat penyakit: tubuh:kompres dingin/
Metabolik evaporasi/ selimut pendingin
Kehilangan cairan (cooling bankat)
Penyakit SSP Mencukupi kebutuhan cairan
Lain –lain :........................................... peroral
Memberikan oksigesn sesuai
dengan instrukasi
Melakukan pengambilan darah
untuk pemeriksaan:
AGD/Elektrolit
Memberikan terapi antipiretik
Memberikan cairan melalui
intravena
 Lain- lain :..................................................

F. Fahrenheit (Suhu Tubuh) Aktual Resiko Mengobservasi, TTV, Kesadaran,

Suhu :.................ºc Gangguan suhu Hypothermia saturasi Oksigen, irama jantung
Lamanya terpapar suhu Melindungi pasien dari lingkungan
panas/ dingin......................Jam yang dingin
Riwayat Pemakain Obat Membuka semua pakaian pasien
Riwayat penyakit: yang basa
Cidera Kepala Melakukan penghangatan tubuh
Hipoglikemia pasien secara bertahap (1ºC/jam)
Dampak Tindakan Medis dengan selimut tebal/ warm
(latrogenic) blanket
Lain –lain :........................................... Mengkaji tanda – tanda cedera
fisik akibat cidera dingin: kulit
melepuh, edema, timbul bula/
vesikel, menggigil.
Menganjurkan pasien agar tidak
menggosok/menggaruk kulit yang
melepuh
Mengantisipasi jika tindakan
daiast gagal melakukan gastric
lavage dengan air hangat

Kolaborasi untuk:
Memberikan oksigen sesuai
dengan instruksi
Memberikan cairan melalui
intravena dengan cairan yang
hangat
Menyiapkan alat – alat intubasi
jika diperlukan
Lain- lain :..................................................

Form : Tindakan Keperawatan dan Evaluasi

Nama Pasien :........................................................
No. Medical Record :........................................................
Tanggal :.......................................................
Jam TINDAKAN KEPERAWATAN Paraf Jam EVALUASI Paraf

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