FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :
Jam Pengkajian :

I. Identitas Klien
1. Nama : ………………………………………………………………………………………..
2. No RM : ………………………………………………………………………………………...
3. Tanggal lahir / Umur : ………………………………………………………………………………………..
4. Alasan masuk RS :
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5. Diagnosa medis : ………………………………………………………………………………………..

II. Pengkajian
A. Primary survey
1. Respon
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2. Airway
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3. Breathing
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4. Circulation
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 5. Disability
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6. Exposure
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B. Secondary survey
1. Riwayat penyakit sekarang :
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2. Riwayat kesehatan terdahulu:
a. Penyakit yang pernah dialami
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b. Alergi (obat, makanan, dll)
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c. Obat-obat yang digunakan
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3. Pengkajian Head to toe
Keadaan umum :
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Tanda vital & nyeri
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a. Kepala
Inspeksi :
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Palpasi :
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b. Leher
Inspeksi :
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Palpasi :
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c. Dada

Paru Jantung
Inspeksi : Inspeksi :

Palpasi : Palpasi :

Perkusi :
Perkusi :

Auskultasi :
Auskultasi :

d. Abdomen
Inspeksi : .......................................................................................................................................
Auskultasi : .......................................................................................................................................
Palpasi : .......................................................................................................................................
Perkusi : .......................................................................................................................................
e. Urogenital
Inspeksi : .......................................................................................................................................
 Palpasi : .......................................................................................................................................

f. Ekstremitas
Ekstremitas Atas
Inspeksi : .......................................................................................................................................
Palpasi : .......................................................................................................................................
Ekstremitas Bawah
Inspeksi : .......................................................................................................................................
Palpasi : .......................................................................................................................................
g. Punggung
Inspeksi : .......................................................................................................................................
Palpasi : .......................................................................................................................................

4. Tindakan prehospital
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5. Pemeriksaan penunjang
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 CATATAN PERKEMBANGAN
MASALAH
ANALISA DATA INTERVENSI IMPLEMENTASI EVALUASI
KEPERAWATAN