BAGIANKGD FORMAT PENGKAJIANKEPERAWATANKRITIS

STIKesWN

I. Identitas Mahasiswa
Nama MHS : ni kadek
wiranti

NIM : 201801023
Kelompok:
TglPraktek:

II. IdentitasKlien
Nama : Agust
Umur : 27 tahun
No.MR :-
Jenis Kelamin : laki - laki
Tanggal : 20 September 2021
Hari rawatke : pertama
Agama : keristen
Status : kecelakaan
Alergi : obat ciprofloxaxin
Beratbadan : 56kg
Alamat Rumah : jln. muhammadiyah
Diagosa Medis : penurunan kesadaran

III. Alasan dirawat diICU

Pasien masuk rumah sakit karena megalami kecelakaan lalu lintas dan sempat pingsan
selama 10 menit, hasil pemeriksaan GCS 11, td 160 mmhg, respirasi 28x/menit, nadi
88x/menit, saturasi oksigen 92% danmuntah sebanyak 3 kali.

IV.PengkajianFisik DanPengkajianUmum

Kardiovaskuler Muskuloskeletal
Normal Normal

Dx.Kep: Dx.Kep:

Pernafasan Genitourinaria
RR 28x/menit Normal

Dx.Kep:Ansietas Dx.Kep:

NeurologisdanSensori Integumen
Lemah dan lemas, sempat mengalami Normal
pingsan

Dx.Kep: Dx.Kep:
BAGIANKGD FORMAT PENGKAJIANKEPERAWATANKRITIS
STIKesWN

Gastrointestinal Endokrin
Normal Normal
 Dx.Kep: GG kebutuhanNutrisi Dx.Kep:

NutrisiKlien Psikososial

Dx.Kep: Dx.Kep:

Cairan IstirahatTidur
Makanan masuk lewat oral, cairan infuse
terpasang RL 20 tts/menit, telah
terpasang infuse 2 kolf/24 jam.

Dx.Kep: Dx.Kep:

V.MonitoringTiapJam
6 7 8 9 10 11 12 13 14
H 40
E
M
O
D
39
I
N
A
M
I
K 38

37

36

35
Kesadaran
Irama EKG
Nyeri
CVP

Resp TipeVent
PEEP/
CPAP
RR
TV
 Neuro Mata
Ukuran
Reaksi
Kaki
Tangan
GCS
Input Line1

Line2

Line3

Line4

Enteral

Total
Output NGT
Urine
BAB
Drain
Total

VI.Terapi/Program Medis
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VII.HasilUjiDiagnostik
Hasil pemeriksaan fisik GCS 11 , muntah 3 kali selama 24 jam tekanan darah 160 mmhg,
Frekuensi nafas 28x/menit, frekuensi nadi 88x/menit, suhu 27C, saturasi oksigen 92%, irama
EKG normal, makanan masuk lewat oral, cairan infus terpasang RL 20 tt/menit, telah
terpasang infuse 2kolf/24 jam, cateter 300cc/3
jam .............................................................................................................................................
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TanggalPengkajian: TANDATANGAN PENGKAJI:

Jam :
Keterangan:

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 BAGIANKGD FORMATPENGKAJIANKEPERAWATANGAWATDARURAT
STIKesWN
I. IdentitasMahasiswa
Nama MHS :
NIM :
Kelompok:
TglPraktek:

II. IDENTITASKLIEN
NAMAKLIEN :
USIA/TGLLAHIR :
JENIS KELAMIN :
TANGGALMASUK :
NO REGISTER :
DIAGNOSAMEDIK :

TRIAGE: P1 P2 P3 P4

III. KELUHAN UTAMA ALASANMASUKRS

P :………………………………………………………………………………………………..
………………………………………………………………………………………………..
Q :………………………………………………………………………………………………..
………………………………………………………………………………………………..
R :………………………………………………………………………………………………..
………………………………………………………………………………………………..
S :………………………………………………………………………………………………..
………………………………………………………………………………………………..
T :………………………………………………………………………………………………..
………………………………………………………………………………………………..

IV. PENGKAJIANPRIMER
AIRWAY
SUMBATAN:
JalanNafas: Paten TidakPaten
Obstruksi: Lidah CairanBendaAsingT/A
SuaraNafas :Snoring/mdgkrGurgling/brdengukStridor/berisiksepanginT/A Perhatian
:Cederaservikal

BREATHING
Sesak,dengan:
Aktifitas....................................................................................
Tanpaaktifitas.........................................................................N
afascupinghidung...............................................................Men
ggunakanotottambahan.................................................
Frekuensi
Irama:
Teratur.....................................................................................
Tidakteratur............................................................................
Kedalaman
Dalam ..................................................................................
Dangkal................................................................................
Cepat....................................................................................
Batuk:
Produktif...............................................................................
Nonproduktif........................................................................
 Bunyinafastambahan:
Ronkhi..................................................................................
Crackles/celah,retak ............................................................
Wheezing/Mencuit2..............................................................

CIRCULATION
Kesadaran: .............................................................................
Sirkulasiperifer :.......................................................................
Nadi :........................
Irama:........................
Teratur/Tidakteratur :.........................................................
Denyut:
Lemah..................................................................................K
uat .....................................................................................
Tidakkuat.............
Tekanandarah:.........
Ekstremitas :..............
Hangat..................
Dingin..................
Warnakulit:
Cyanosis ..............
Pucat....................
Kemerahan...........

DISABILITY
Pemeriksaanneurologissingkat
Respon:
Alert/perhatian......................................................................
Voice respons/responterhadapsuara.................................
Painrespons/responterhadapnyeri.....................................
Unresponsive/tidakberespon...............................................R
eaksipupil..........................................................................

EKSPOSURE/ENVIRONMENT/EVENT
Deformitas:YaTidakContusi
o: YaTidakAbrasi:
YaTidakPenetrasi:
YaTidakLaserasi:
YaTidak Edema :
YaTidakKeluhanLain:
…………..…………………………………………………………..
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V. PENGKAJIANSEKUNDER
Riwayatkesehatansekarang....................................................Ri
wayatkesehatankeluarga....................................................Ana
mnesasingkat(AMPLE)......................................................
Allergies.............................
Medikasi............................
Nyeri..................................
Terakhirkalimakan...........
Eventofinjury/penyebabinjury..........

Pemeriksaan head to toe

- Kepala
Rambut:
- Mata :

- Telinga:
 - Hidung:

- Mulut:

- Leher
Deviasi/simetns,cederaservikal..........................................K
elenjartiroid.......................................................................Kel
enjarlimfe.......................................................................Trak
ea..................................................................................JVP..
.....................................................................................

- Dada
I :

P :

P :

A :

- Abdomen:
I :

A :

P :

P :

-Ekstermitas/musculoskeletal
Rentang gerak.................................................................
Kekuatanotot..................................................................
Deformitas.......................................................................
Kontraktur .......................................................................
Edema ............................................................................
Nyeri................................................................................
Krepitasi..........................................................................

- Kulit/integumen:
Turgor:
Baik.................
Buruk ..............
Sedang...........
Mukosa:
Lembab...........
Kering..............
Kulit:
Bintikmerah...
Lesi.................Suh
u.....................

VI. PEMERIKSAANPENUNJANG
PemeriksaanRadiologi:Pemeriksa

anLabdarah:

PemeriksaanPenunjanglainnya:
VII. TERAPIMEDIS

TanggalPengkajian: TANDATANGAN PENGKAJI:

Jam :
Keterangan:

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