FORMAT PENGKAJIAN PASIEN DI IGD

I. DATA
DEMOGRAFI
Nama :
Tanggal Lahir :
Jenis Kelamin :
Alamat :
:
No. Rekam Medik :
Tanggal Masuk RS :
Tanggal Pengkajian :
II KELUHAN :
UTAMA
III TRIAGE PRIMER : Emergency Severity Index ESI
ESI LEVEL 1
ESI LEVEL 2
ESI LEVEL 3
ESI LEVEL 4
ESI LEVEL 5
IV SURVEI PRIMER
Airway :  Look:
..................................................................................................
..................................................................................................
...
 Listen:
....................................................................................................
....................................................................................................
.
 Feel:
..................................................................................................
..................................................................................................
..
 Servical-spine control:
....................................................................................................
....................................................................................................
 Kondisi jalan nafas:

Paten
Obstruksi
Stridor
Gurgling
Snoring

Breathing  Look:
..................................................................................................
..................................................................................................
...
 Listen:
....................................................................................................
....................................................................................................
.
 Feel:
..................................................................................................
..................................................................................................
 ..
 Kondisi pernafasan
Spontan Retraksi otot
Apnea Nasal Flare
Sianosis Posisi Tripod

 Ekspansi dada kanan kiri:

..................................................................................................
..................................................................................................
..
 Auskultasi:
..................................................................................................
..................................................................................................
..
 Saturasi Oksigen: (%)
Circulation  Look:
..................................................................................................
..................................................................................................
...
 Listen:
....................................................................................................
....................................................................................................
.
 Feel:
..................................................................................................
..................................................................................................
..
 Nadi
Kuat
Lemah
Tak teraba

 Kulit
Normal Hangat
Pucat Dingin
Sianosis

 CRT: (detik)

Disability  Tingkat Kesadaran dengan GCS

 E:
 V:
 M:
 Pupil:
....................................................................................................
 Reflek cahaya:
....................................................................................................
 Lateralisasi: kanan atau kiri
....................................................................................................
 Jika terjadi penurunan kesadaran, tentukan
penyebabnya dengan AEIOU
Alkohol dan Obat-obatan
Endokrin, encephalophaty
Insulin
Opiat dan Oksigen
 Exposure
Dalam batas normal
Luka
Deformitas
Nyeri Tekan
Pembengkakan

Tanda-tanda vital  TD : (mmHg)

 N: (x/menit)
 S: (C)
 RR: ( x/menit )

 Skor Nyeri:

P:
Q:
R:
S:
T:

V. SURVEI SEKUNDER
a. Keluhan utama
........................................................................................................................
........................................................................................................................
........................................................................................................................
b. Riwayat penyakit sekarang
........................................................................................................................
........................................................................................................................
........................................................................................................................
c. AMPLE
- Alergi :
..................................................................................................................
..................................................................................................................
- Medication :
..................................................................................................................
.................................................................................................................
- Post ilnes :
 ..................................................................................................................
.................................................................................................................
- Last Meal :
..................................................................................................................
.................................................................................................................
- Event :
..................................................................................................................
.................................................................................................................

d. Pemeriksaan fisik
1) Kepala
..................................................................................................................
.................................................................................................................
2) Mata
..................................................................................................................
.................................................................................................................
3) Hidung
..................................................................................................................
.................................................................................................................
4) Mulut
..................................................................................................................
.................................................................................................................
5) Leher
..................................................................................................................
.................................................................................................................
6) Thorax :
- Paru-paru :
..........................................................................................................
..........................................................................................................
- Jantung :
..........................................................................................................
..........................................................................................................
7) Abdomen
.................................................................................................................
.................................................................................................................
 8) Genetalia
.................................................................................................................
.................................................................................................................
9) Ekstermitas atas
.................................................................................................................
.................................................................................................................
10) Ekstermitas bawah
.................................................................................................................
.................................................................................................................

Kekuatan otot:

VI. PEMERIKSAAN PENUNJANG

Jenis Tanggal Tanggal Analisa &
No Hasil Nilai Normal
Pemeriksaan Pemeriksaan Hasil Interpretasi
VII. TERAPI
Dosis & Kontra Efek
No Nama Obat indikasi KET.
Frekuensi indikasi samping

VIII. ANALISA DATA

No Data Masalah Etiologi