SEKOLAH TINGGI ILMU KESEHATAN SANTO BORROMEUS FORM IGD REV I

Nama :
Tgl.Lahir : L/P
PENGKAJIAN MEDIS GAWAT No RM :
DARURAT Diagnosa Medis:

DATA AWAL
Tanggal: JAM:

Rujukan Ya dari  RS ......................................... Puskesmas ...........................................

 Dr. .........................................  Lainnya .................................................
Dx Rujukan ......................................................
Tidak  Datang Sendiri Diantar PMI

TRIAGE
¨ ATS 1 ¨ ATS 2 ¨ ATS 3 ¨ ATS 4 ¨ ATS 5
PENGKAJIAN PRIMER
AIRWAYS
 Assesment :
¨ Bebas ¨ Tersumbat
Trachea di tengah: ¨Ya ¨ Tidak
Lain-lain:
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 Masalah Keperawatan:
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 Resusitasi :
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 Re-evaluasi :
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BREATHING
 Assesment :
Dada simetris : ¨Ya ¨ Tidak Sesak nafas : ¨Ya ¨ Tidak
Respirasi : ............. x/mnt Krepitasi : ¨ Ya ¨ Tidak
Suara nafas :
Kanan : ¨ Ada : ¨ Jelas ¨ Menurun ¨ Ronchi Kiri : ¨ Ada : ¨ Jelas ¨ Menurun ¨ Ronchi
¨ Wheezing, ¨ Tidak Ada ¨ Wheezing, ¨ Tidak Ada

Saturasi O2 : ................%
Pada: ¨ Suhu ruangan ¨ Nasal canule (.......l/m) ¨ NRFM (.......l/m) ¨ NFM (.......l/m)
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¨ Simple Mask (....... /m) ¨ Jackson Rise ¨ Lain-lain.................. (.......l/m)
Lain-lain
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 Masalah Keperawatan:
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 Resusitasi :
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CIRCULATION
 Assesment :

Tensi :............. mmHg Nadi :.............. x/mnt

MAP : .............mmHg ¨ Kuat ¨ Lemah ¨ Regular ¨ Irregular
Gambaran kulit : ¨ Normal ¨ Kering
¨ Lembab/basah
Lain-lain
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 Masalah Keperawatan:
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DISABILITY
 Assesment :
¨ Alert ¨ Pain response
¨ Verbal response ¨ Unresponsive
GCS :
Kuantitatif: E (....) V (....) M (....)
Kualitatif :........................................
REAKSI PUPIL
Kanan Ukuran (mm) Kiri Ukuran (mm)
Cepat ¨ ......... ¨ .........
Konstriksi ¨ ......... ¨ .........
Lambat ¨ ......... ¨ .........
Dilatasi ¨ ......... ¨ .........
Tak bereaksi ¨ ......... ¨ .........

Lain-lain
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 Masalah Keperawatan:
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 Resusitasi :
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 Re-evaluasi :
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EXPOSURE
 Assesment :

Deformitas : ( ) Ya ( ) Tidak ( ) Lokasi: ........................

Contusio : ( ) Ya ( ) Tidak ( ) Lokasi: ........................
Abrasi : ( ) Ya ( ) Tidak ( ) Lokasi: ........................
Laserasi : ( ) Ya ( ) Tidak ( ) Lokasi: ........................
Edema : ( ) Ya ( ) Tidak ( ) Lokasi: ........................
Dekubitus : ( ) Ya ( ) Tidak ( ) Lokasi: ........................
Tanda Kompartmen/DVT: ( ) tidak ada ( ) diketahui
Suhu Axilla : ........... ºC Suhu Rectal : ............ºC
Temperatur kulit : ¨ Hangat ¨ Panas ¨ Dingin
Lain-lain
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 Masalah Keperawatan:
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 Re-evaluasi :
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PENGKAJIAN SEKUNDER
ANAMNESA:
1. Keluhan Utama :
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2. Riwayat Penyakit Sekarang ( Jabarkan lokasi, onset, kronologis, kualitas/kuantitas keluhan tsb dan faktor-faktor/gejala yang
menyertainya):
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3. Riwayat Penyakit Sebelumnya:
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4. Keadaan Umum:
Pasien tampak
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RIWAYAT AMPLE
¨ Alergi : .....................................................
¨ Medikasi : .........................................................
¨ Penyakit lain/penyerta : ..........................................................
¨ Makan terakhir, jam : Tidak terkaji, Pengaruh NAPZA : ¨ Tidak ¨ Ya, jenis....................................................
¨ Suntikan Anti Tetanus terakhir : ¨ Tidak terkaji
 Hamil : ¨ Tidak ¨ Ya: Umur kehamilan : ............. bulan ¨ Menstruasi terakhir : ................................
¨ Kejadian-kejadian yang lain : ....................................................................................................................................

TINDAKAN PREHOSPITAL SKALA NYERI :….

¨ C-Spine Protection : ¨Tidak ¨Ya, ............................
¨ Airway device : ¨Tidak ¨Ya, ............................
¨ IV Line : ¨Tidak ¨Ya..............................
¨ Medications : ¨Tidak ¨Ya..............................
¨ Lain-lain : ...............................................................................

PEMERIKSAAN HEAD TOE TOE

1. Kepala dan Leher
 Anamnesa :
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2. Dada
 Anamnesa :
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 Inspeksi :
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3. Abdomen
 Anamnesa :
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 Inspeksi :
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4. Pelvis
 Anamnesa :
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5. Sistem Muskoloskeletal
 Anamnesa :
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 Inspeksi :
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6. Punggung
 Anamnesa :
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 Inspeksi :
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7. Sistem Integumen
 Anamnesa :
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8. Sistem Neurologi
 Anamnesa :
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9. Perineum/Rektal/Vagina
 Anamnesa :
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TERAPI OBAT
Nama obat :
Golongan :
Dosis untuk pasien :
Indikasi untuk pasien :
Kontra indikasi obat :
Efek samping obat :
Farmakokinetik :

Nama obat :
Golongan :
Dosis untuk pasien :
Indikasi untuk pasien :
Kontra indikasi obat :
Efek samping obat :
Farmakokinetik :

Nama obat :
Golongan :
Dosis untuk pasien :
Indikasi untuk pasien :
Kontra indikasi obat :
Efek samping obat :
Farmakokinetik :
Nama obat :
Golongan :
Dosis untuk pasien :
Indikasi untuk pasien :
Kontra indikasi obat :
Efek samping obat :
Farmakokinetik :

Nama obat :
Golongan :
Dosis untuk pasien :
Indikasi untuk pasien :
Kontra indikasi obat :
Efek samping obat :
Farmakokinetik :

Nama obat :
Golongan :
Dosis untuk pasien :
Indikasi untuk pasien :
Kontra indikasi obat :
Efek samping obat :
Farmakokinetik :

Nama obat :
Golongan :
Dosis untuk pasien :
Indikasi untuk pasien :
Kontra indikasi obat :
Efek samping obat :
Farmakokinetik :
LAIN-LAIN
Diit : ……………………………………………………………………..
Acara Infus : ……………………………………………………………………..
Mobilisasi: : ……………………………………………………………………..
PEMERIKSAAN PENUNJANG
Laboratorium :

Tanggal : …………………………… Pukul : …………………………………….

Pemeriksaan Hasil Satuan Nilai normal

Radiologi :
Nama dan Tanda Tangan Perawat Pengkaji

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PENGELOMPOKAN DATA DAN ANALISA DATA

1. Pengelompokan Data

Data Subjektif Data Objektif

2. Analisa Data

N Data Etiologi Masalah

O
1 DS :

DO :

2 DS :

DO :

3 DS :

DO :

DIAGNOSA KEPERAWATAN

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INTERVENSI KEPERAWATAN
 No
Dk SDKI SLKI SIKI Rasional

IMPLEMENTASI KEPERAWATAN

Tgl Jam No.Dk Implementasi Nama & Ttd

EVALUASI KEPERAWATAN

Tgl No. Dk SOAP Nama & Ttd

S :

O :

A :

P :
S :

O :

A :

P :