FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Nama Mahasiswa :.........................................................................................................

Semester/Tingkat :.........................................................................................................
Tempat Praktek :.........................................................................................................
Tanggal Pengkajian :.........................................................................................................

DATA KLIEN

A. DATA UMUM
1. Nama inisial klien : .........................................................
2. Umur :.........................................................
3. Alamat :.........................................................
4. Agama : .........................................................
5. Tanggal masuk RS/RB : .........................................................
6. Nomor Rekam Medis : .........................................................
7. Bangsal : .........................................................

B. PENGKAJIAN PRIMER:
1. Respon:
(.....) Alert/sadar
(.....) Verbal
(.....) Pain
(.....) Unrespon
2. Air Way (Jalan Nafas) + Control Servikal
a. Jalan nafas:
(.....) Sesak
(.....) Takipnea (20 – 30 – 40)
(.....) Gasping
(.....) Cyanosis
(.....) Retraksi Supra sternal
(.....) Intra sternal
(.....) Inter sternal
b. Bunyi pernafasan:
(.....) Gurgling (cairan)
(.....) Snoring (lidah)
(.....) Stridor (
c. Control Servikal:
(.....) Trauma Capitis, disertai penurunan kesadaran.
(.....) Trauma tumpul di atas Clavikula.
(.....) Multipel trauma
d. Biomekanik Trauma:
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3. Breathing (Pernafasan) + Control Ventilasi
a. Pulse Oxymetry : .......................
b. Inspeksi :
(.....)sesak; RR : ............. X/mnt.
 (.....)jejas pada dada
(.....) lukaterbuka pada thoraks
(.....) JVP meningkat
(.....)Deviasi trakea.

Ekpansi thorak Kanan: ............../ Kiri :....................

c. Auskultasi :
1) Dada kanan : (.....)vesikuler; (.....)tidak terdengar/menjauh
2) Dada kiri : (.....)vesikuler; (.....)tidak terdengar/menjauh

d. Perkusi :
1) Dada kanan : (.....)Sonor, (.....)hipersonor, (.....) dull
2) Dada kiri : (.....)Sonor, (.....)hipersonor, (.....) dull

e. Palpasi :
1) Dada kanan : (.....) nyeritekan, (.....) krepitasi
2) Dada kiri : (.....) nyeritekan, (.....) krepitasi

4. Circulation + Control Perdarahan

a. Perdarahan:
1) Eksternal : .......................................................................................................................
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2) Internal :
a) Thoraks :................................................................................
b) Abdomen :................................................................................
c) Pelviks :................................................................................
d) Femur :................................................................................
e) Retro perinial :................................................................................

b. Nadi :........................................................................
c. Capilarry refill :........................................................................
d. Akral :.........................................................................
e. Cyanosis :.........................................................................

5. Disability
a. GCS
E: ..... M: ........ V: ......
b. Lateralisasi pupil
1) Pupil :isokor/anisokor
2) Reflekcahaya :............../....................
3) Dilatasi :............../....................
c. Motoric
1) Kekuatan tonus otot :......................................./........................................
2) Lateralisasi motoric :......................................../.......................................

6. Exposure (CeksemuabagianTubuh)
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7. Foley Catheter
a. Kontra Indikasi
(.....) Perdarahanorifisium urethra eksterna
(.....) Hematomskrotum
(.....) prostatmelayang

b. Evaluasi urin :.....................cc/...............jam

8. Gastric Tube
a. Kontra indikasi:
(.....) Braille Hematom
(.....) Rhinorea
(.....) Othorea
(.....) Echymosis/Battle sign

b. Distensi
Abdominal: .............................................................................................................................
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9. Heart Monitor
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C. SECONDERY SURVEY
1. Head to Toe Examination (BTLS) :
a. Kepala :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

b. Leher :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

c. Thoraks :
- B : ..............................................................................................................
- T : ..............................................................................................................
 - L : ...............................................................................................................
- S : ...............................................................................................................

d. Abdomen.
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

e. Pelvis :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

f. Ektremitas
1. Atas :
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

2. Bawah:
- B : ..............................................................................................................
- T : ..............................................................................................................
- L : ...............................................................................................................
- S : ...............................................................................................................

2. Vital Sign
a. Frekuensi Nadi : ....................x/mnt.
b. Tekanandarah :......................mmHg
c. Frekuensipernafasan :......................x/mnt
d. Suhu :…...................oC
e. Saturasioksigen :.......................%

3. Finger in every orifice (coloksemualubang)

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4. Anamnesa KOMPAK
a. K : ..............................................................................................................
b. O : ..............................................................................................................
c. M : ...............................................................................................................
d. P : ...............................................................................................................
e. A : ...............................................................................................................
f. K : ...............................................................................................................
 5. Pemeriksaantambahan
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6. Persiapanrujuk: kerumahsakitatauruangan lain

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D. Reevaluasi

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