FORMAT LAPORAN ANALISA SITESA RUANGAN GAWAT DARURAT

Nama Mahasiswa :………………………………………..

No Npm :……………………
Nama Pasien :……………………… Umur:…………………….
No RM :……………………..
Diagnosa Medis :……………………………………………………………..
Tanggal : jam masuk :

Respons : Alert: Verbal Respons : Pain Respons: Un Respons :

Triase : Emergency : Urgen : Non Urgen :

Laporan dibuat setiap hari dan dikumpulkan setiap minggu

1. Pengkajian primer (Airway, Breathing, Circulation, Disability, Exposure)

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2. Diagnosa keperawatan NCP Primary Survey ( jika ada masalah di primary )
No Diagnosa Keperawatan Noc Nic Aktifitas Evaluasi Paraf

1. (Airway) - Jam :

Dx :

d.d

DS :

DO:
2. (Breathing) Jam :

Dx :

d.d

DS :

DO:
3. (Circulation) Jam :

Dx :

d.d

DS :

DO:
4. Disability Jam :

Dx :

d.d

DS :

DO :
1. Pengkajian sekunder Survey (meliputi pengkajian riwayat kesehatan dan pengkajjian
head to toe)
a. Anamnesa
Keluhan Utama :

Riwayat kesehatan sekarang :

Riwayat Kesehatan Dahulu :

Riwayat Kesehatan Keluarga :

b. Pemeriksaan Fisik
1. Kesadaran :

2. Skala Nyeri :

3. TTV : TD: Nadi: Suhu : RR :

4. Head To toe
a. Kepala :

b. Leher :

c. Dada :
 d. Paru ` :

e. Jantung :

f. Abdomen :

g. Pelvis :

h. Genetalia :

i. Tulang Belakang :

j. Extremitas :

2. Pemeriksaan penunjang
 Laboratorium ( cantumkan Hasilnya dan normalnya)

 Radiologi ( Cantumkan Hasilnya )

  EKG ( Cantumkan Hasilnya )

3. Diagnosa Medis

4. Therapi

5. Data lain
6. Diagnosa keperawatan NCP pada secondary Survey ( selaim pada primary survey )
No Diagnosa Keperawatan Noc Nic Aktifitas Evaluasi Paraf

1 Jam :
2
3
7. Monitoring ( pada pasien yang diobservasi )

Jam Kesadaran TD Suhu Nadi/HR RR SpO2 Tindakan /Obat

Tindak lanjut pasien : Rawat inap, ICU, ICCU, HCU atau CVCU, Pulang, Rujuk / pindah, Meninggal

8. Evaluasi diri
a. Kelebihan

b. Kekurangan
9. WOC KASUS
 BAGIAN KEPERAWATAN GAWAT DARURAT PROGRAM STUDI ILMU
KEPERAWATAN STIKBA JMABI
FORMAT PENGKAJIAN
(ICU, CVCU, HCU atau HCU)

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

No NPM :……………………………… Tempat Praktek :..………………......
Nama Pasien :……………………………… Umur :...............................

I. Pengkajian Primer
Airway
:……………………………………………………………………………………...
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Breathing
:……………………………………………………………………………………..
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Circulation
:……………………………………………………………………………………..
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Disability
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II. Identitas Pasien

Nama Pasien :………………… Tanggal Masuk :……………..
Tampat/tgl lahir :………………… Status perkawinan :……………..
Agama :………………… Suku :……………..
Pendidikan :…………………
Pekerjaan :………………… Lama bekerja :……………..
Alamat :……………………………………………………………………..
 Sumber Informasi :………………………………………………………………….
Keluarga dekat yang dapat dihubungi:
Nama :…………………………………………………………………
Pendidikan :…………………………………………………………………
Pekerjaan :…………………………………………………………………
Alamat :…………………………………………………………………
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III. Status Kesehatan Saat Ini

Alasan Kunjungan/keluhan utama:
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Faktor Pencetus
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Lama keluhan
…………………………………………………… Mendadak / bertahap
Faktor yang memperberat
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Upaya yang dilakukan untuk mengatasi
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Diagnosa medic
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IV. Riwayat Kesehatan yang Lalu

Riwayat kesehatan Dahulu
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Alergi
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Kebiasaan merokok / kopi / alcohol / dll
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Obat-obatan yang sering digunakan (nama dan frekuensi)
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Pola Nutrisi
BB………………………………… TB………………………………….
Frekuensi makan…………………………………………………………………..
Jenis makanan……………………………………………………………………..
Makanan yang disukai…………………………………………………………….
Nafsu makan dalm 6 bulan terakhir……………………………………………….
Perubahan berat badan dalm 6 bulan terakhir………………………… + / -
 Pola Eliminasi
Buang air besar
Frekuensi…………………………… Waktu………………………………
Warna……………………………… Konsentrasi…………………………
Kesuliatan…………………………………………………………………………
Buang air kecil
Frekuensi………………………….. Warna………………………………
Kesuliatan……………………………………….…………………………………
Pola tidur dan istirahat
Lama tidur…………….………….. Waktu………………………………
Kesuliatan...…………………………………………………………………………

Pola Aktifitas dan latihan

Kegiatan dalam pekerjaan
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Olahraga
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Keluhan dalam
beraktifitas…………………………………………………………………………
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Pola pekerjaan
Jenis…………………………….. Lama ……………………………….
Jadwal…………………………... Jumlah jam……………….…………

V. Riwayat Keluarga
RKK
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Genogram
VI. Pemeriksaan Fisik
Kepala
Inspeksi
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.
Palpasi…………………………………………..…………………………………..
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Keluhan……………………………………………………………………………
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.
Mata (I/P/P/A)
Fungsi penglihatan……………………………… Palpebra terbuka /
tertutup
Ukuran pupil……………………………………………. Isokor / unisokor
Akomodasi……………………………………………… Isokor / unisokor
Konjungtiva…………………………………………………………………………
Skelerra……………………………………………………………………………..
Edema Palpebra……………………………..……………..……………………….
Keluhan………………………………………………………..……………………
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Telinga
Inspeksi……………………………………………………………………………..
Palpasi………………………………………………………………………………
Fungsi pendengaran………………...……………………………………………….
Fungsi keseimbangan
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Keluhan
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Mulut dan tenggorokan

Inspeksi……………………………………………………………………………..
Keadaan
gigi…………………………………………………………………………………
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..
Membran
mukosa……………………………………...………………………………………
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Kesulitan
menelan……………………………………………………………………………
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....
Leher
Inspeksi……………………………………………………………………………
Palpasi………………………………………………………………………………
Auskultasi…………………………………………………………………………..

Thoraks
Inspeksi……………………………………………………………………………..
Palpasi………………………………………………………………………………

Paru
Perkusi………………………………………………………………………………
Auskultasi…………………………………………………………………………...
Keluhan
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Jantung
Perkusi………………………………………………………………………………
Auskultasi…………………………………………………………………………...
Pola
ventilator…………………………………………………………………………....
Deskripsi
ventilator……………………………………………………………………...........
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EKG…………………………………………………………………………………
….
JVP………………………………………………………………………………...
Sirkulasi
Frekuensi nadi…………………………... Sa O2…………………………..
TD………………………………………. MAP……………………...……
CVP.......................................................... PAP……………………………
PA systole………………………………. PA diastol……………………….
Suhu……………………………….......... Suhu ekstremitas………………
Sianosis bibir / kuku……………………. Pucat…………………………..
Turgor……………………………………………………………………………..

Abdomen
Inspeksi………………………………………...……………………………………
Palpasi………………………………………………………………………………
Perkusi………………………………………………………………………………
Auskultasi…………………………………………………………………………..
Jenis diet……………………………….... Nafsu makan……………………
NGT…………………………………………………………………………………
Keluhan……………………………………………………………………………..
 Eliminasi
Frekuensi BAB………………………….. Konsistensi……………………
Keluhan……………………………………………………………………………
Kateter…………………………………... Hematuris ……………………..
Keluhan BAK : ……………………………………………………………………
Riwayat Kehamilan : ………………………………………………………………
Perdarahan pervaginam : ………………………………………………………….
Keluhan sistem Reproduksi : ……………………………………………………..
Ekstremitas
Inspeksi : ……………………………………………………………………..
Masa otot : ………………………………Tonus Otot : ……………………..
Kekakuan : ……………………................kejang : ………………………….
VII. Data Laboratorium

VIII. Hasil pemeriksaan Diagnostik

IX. Pengobatan

X. Kesimpulan
 BAGIAN KEPERAWATAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN BAITURRAHIM

LEMBAR OBSERVASI
Nama Mahasiswa : ……………………………Tanggal Praktek : ………………………
No NPM : …………………………….Ruang Praktek : ……………………….
Nama Pasien : …………………………… Umur : ……………………………….L/P
Tanggal : Jam

Sistem Tingkat kesadaran

Neurologi Ukuran Pupil
Reaksi Pupil
GCS
Sistem Jenis Ventilator
pernafasan PEEP
Ferkuensi Nafas
Sistem Tekanan darah
kardiovasuler MAP
Frekuensi Nadi
CVP
Suhu Tubuh
PA Sistolik
PA Diastolik
PA Mean
Sat O2
Cairan Masuk Enteral
Parenteral
Lain
Cairan keluar Urin
Enteral
Lain
Analisa Gas Pa H
Darah Pa O2
Pa CO2
HCO3
Sa O2
BE
Elektrolit Na
K
Cl
 ANALISA DATA

No Data Penyebab Masalah

 NCP (Nursing Care Plan)

Nama Mahasiswa :
NPM :

No Diagnosa Keperawatan Noc Nic Aktivitas

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 IMPLEMENTASI

Nama Mahasiswa :
NPM :

No Jam Diagnosa Keperawatan Implementasi Evaluasi Paraf

 IMPLEMENTASI

Nama Mahasiswa :
NPM :

No Jam Diagnosa Keperawatan Implementasi Evaluasi Paraf

 SISTEMATIKA PENULISAN
LAPORAN ANALISA (RESUME)
(ICU, CVCU, HCU dan ICU)

Nama Mhs : Ruang :

NPM : Tanggal :

1. Identitas klien
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2. Data Pengkajian

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3. Datang Penujang
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4. Diagnosa medis
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5. Diagnosa keperawatan
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6. Noc
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7. Nic
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8. Evaluasi
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