BAGIAN KEPERAWATAN GAWAT DARURAT FAKULTAS KEPERAWATAN

UNIVERSITAS ANDALAS

FORMAT PENGKAJIAN

Nama Mahasiswa : ................................. Tanggal Praktek : ..........................

No BP : ................................. Tempat Praktek : ..........................

Nama Pasien : ............................................... Umur L/P

I. Pengkajian Primer
A:

B:

C:

D:

E:

II. Data Demografi

Nama Lengkap : .............................................Tanggal masuk RS : ..................
Tempat/tgl lahir : .............................................Status perkawinan : ..................
Agama : .............................................Suku : ..................
Pendidikan : ........................................................
Pekerjaan : .............................................Lama bekerja : ..................
Alamat : ................................................................................................... ...........................
......................................................................
Sumber Informasi : .....................................................................................

Keluarga terdekat yang dapat dihubungi:

Nama : ............................................
Pendidikan : ............................................ Pekerjaan : ..........................
Alamat : ..................................................................................................
III. Status Kesehatan Saat Ini
Alasan Kunjungan/keluhan utama:
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
....................................................................................................... ..................................................
Faktor pencetus:
.........................................................................................................................................................
...........................................................................................................................................................

Lamanya keluhan: ................................................................Mendadak / Bertahap

Faktor yang memperberat: ...............................................................................................................
...........................................................................................................................................................
.......................... .................................................... ..........................................................................
Upaya yang dilakukan untuk
mengatasi: .........................................................................................................................................
................
.........................................................................................................................................................
Diagnosa Medik:
.............................................................................Tanggal ..............................
...................................................,....................... Tanggal ..............................
....................................................,...................... Tanggal ..............................

IV. Riwayat Kesehatan yang lalu

Penyakit yang pernah dialami (jenis penyakit, lama dan upaya mengatasi)
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Alergi : ................................................................................................................... ..................... .....
Kebiasaan : merokok / kopi / alkohol / lain-lain ...................................................... ........................
Obat-obatan yang sering digunakan (nama dan
frekwensi) ..........................................................................................................................................
........................................................................................................................ ..................................
. ................................... ................................... ................................... ...................................
Pola Nutrisi :
Berat badan : ..........................................Tinggi badan : ...............................
Frekwensi makan : ........................................................................................
Jenis makanan : ............................................................................
Makanan yang disukai : .............................................................................
Makanan yang tidak disukai : .........................................................................
Nafsu makan dalam 6 bulan terakhir : Baik / Sedang / Kurang
 Perubahan berat badan 6 bulan terakhir :.......... Kg Bertambah / Berkurang

Pola Eliminasi :
Buang air besar
Frekwensi : ................................ Waktu : .....................................
Warna : ................................ Konsistensi : .........................
Kesulitan : ....................................................................................
Buang air kecil
Frekwensi : .............................. Warna : .........................
Kesulitan : ....................................................................................

Pola tidur dan istirahat

Lama tidur : ................................ Waktu : .....................................
Kesulitan dalam hal tidur : .........................................................................

Pola aktivitas dan latihan

Kegiatan dalam pekerjaan : .........................................................................
Olah raga rutin (jenis dan
frekwensi) : ........................................................................................................................................
....................................................................................................... ......................................................
...................
Kegiatan di waktu luang
: ........................................................................................................................................
Keluhan dalam beraktivitas : ..........................................................................

Pola Bekerja
Jenis pekerjaan : ................................. Lama bekerja : ......................
Jadwal kerja : ................................. Jumlah jam kerja : .....................

V. Riwayat Keluarga
Genogram beserta penyakit yang dialami oleh anggota keluarga lain
VI. Pengkajian Sekunder

Kepala
Inspeksi / Palpasi : ........................................................................................
Keluhan : ........................................................................................

Mata
Fungsi penglihatan : .............................. Palpebra : Terbuka / tertutup
Ukuran pupil..............................................................Isokor / Unisokor
Akomodasi.................................................................Isokor / Unisokor
Konjungtiva : ................................. Sklera : ..............................

Edema Palpebra : .........................................................................................

Keluhan................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
................. ................................................................. ................................................................. ........

Telinga
Fungsi Pendengaran : ..................................... Fungsi keseimbangan : .....
Keluhan : ........................................................................................
Hidung dan sinus
Inspeksi : .........................................................................................
Pembangkakan : .......................................... Pendarahan : .....................
Keluhan : .........................................................................................
Mulut dan tenggorok
Inspeksi : .........................................................................................
Keadaan gigi : .........................................................................................
Keadaan membran mukosa : .........................................................................
Kesulitan menelan : .........................................................................
Leher
Inspeksi / palpasi : .........................................................................................
Auskultasi : .........................................................................................
Thoraks
Inspeksi : .........................................................................................
Palpasi : .........................................................................................
Perkusi Paru : .........................................................................................
Perkusi Jantung : .........................................................................................
Auskultasi Paru : .........................................................................................
Mode ventilator : .........................................................................................
Deskripsi ventilator : ...................................................................................................
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 Auslkultasi Jantung : .....................................................................................
Gambaran EKG : ... .....................................................................................................................
..............................................................................................................................................................
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Sirkulasi
Frekwensi nadi : ......................................... Sa O2 : .............................
Tekanan darah : ........................... MAP : .............. CVP : ............
Suhu tubuh : ........................... Suhu ekstremitas : ...........................
Sianosis : Bibir / kuku ...................... Pucat : ..............................
Turgor :....................................................................................................
Abdomen
Inspeksi : .......................................................................................
Auskultasi : ........................................................................................
Palpasi : ........................................................................................
Perkusi : ........................................................................................
Jenis diet : ................................ Nafsu makan : .............................
Pengeluaran NGT : .........................................................................................
Frekwensi BAB : ................................ Konsistensi feses : ........................
Keluhan makan dan BAB : ............................................................................
Frekwensi BAK : ................................ Volume Urin : .............................
Penggunaan kateter : ............................ Hematuri : .............................
Keluhan BAK : ........................................................................................
Riwayat Kehamilan : ......................................................................................
Perdarahan pervaginam : ............................................................................
Keluhan sistem reproduksi : ..........................................................................
Ekstremitas
Inspeksi : ...................................................................................................
Masa otot : ........................................ Tonus otot : .....................................
Kekakuan : ........................................ Kejang : ........................................
VII. Data Laboratorium
VIII. Hasil Pemeriksaan Diagnostik lain

IX. Pengobatan

X. Kesimpulan

XI. Daftar Pustaka

 FORMAT RENCANA ASUHAN KEPERAWATAN GAWAT DARURAT

Diagnosa Keperawatan
No Luaran dan Kriteria Hasil Intervensi Aktivitas
dan Data Penunjang
 FORMAT RENCANA ASUHAN KEPERAWATAN GAWAT DARURAT

Diagnosa Keperawatan
No Luaran dan Kriteria Hasil Intervensi Aktivitas
dan Data Penunjang
 FORMAT RENCANA ASUHAN KEPERAWATAN GAWAT DARURAT

Diagnosa Keperawatan
No Luaran dan Kriteria Hasil Intervensi Aktivitas
dan Data Penunjang
 FORMAT CATATAN PERKEMBANGAN

Diagnosa
No Implementasi Evaluasi
Keperawatan
 FORMAT CATATAN PERKEMBANGAN

Diagnosa
No Implementasi Evaluasi
Keperawatan
 FORMAT CATATAN PERKEMBANGAN

Diagnosa
No Implementasi Evaluasi
Keperawatan