KEMENTERIAN KESEHATAN R.

I
POLITEKNIK KESEHATAN JAMBI
JURUSAN KEPERAWATAN
JL.DR. TAZAR KELURAHAN BULURAN KENALI KEC. TELANAIPURA JAMBI

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...
IDENTITAS

Nama : Jenis Kelamin : L/P Umur :

Agama : Status Perkawinan : Pendidikan :
Pekerjaan : Sumber informasi : Alamat :

TRIAGE P1 P2 P3 P4
GENERAL IMPRESSION
Keluhan Utama :

Mekanisme Cedera (Jika pasien ada riwayat trauma) :

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...

Diagnosa Keperawatan:
Bersihan jalan nafas tidak efektif b/d …
……
AIRWAY
PRIMER SURVEY

Jalan Nafas :  Paten  Tidak Paten Kriteria Hasil : … … …

Obstruksi :  Lidah  Cairan  Benda Asing
Intervensi : (saran pisah kotak)
Suara Nafas : Snoring Gurgling 1. Manajemen airway;headtilt-chin lift/jaw
thrust
Crowing/Stridor  N/A
2. Pengambilan benda asing dengan
Keluhan Lain: ... ... forcep
3. Suction
4. … …

Diagnosa Keperawatan:
1. pola nafas tidak efektif b/d … … …
2. Kerusakan pertukaran gas b/d … …
BREATHING …
3. ..................

Gerakan dada:  Simetris  Asimetris Kriteria Hasil : … … …

Irama Nafas :  Cepat  Dangkal  Normal
Intervensi :
Pola Nafas :  Teratur  Tidak Teratur(tambah jenis 1. Pemberian terapi oksigen … …
ltr/mnt, via… …
pernapasan)
2. Bantuan dengan Bag Valve Mask
Retraksi otot dada :  Ada  N/A (norrmal) 3. Persiapan ventilator mekanik
4. Mengatur Posisi fowler, semifowler
 Sesak Nafas :  Ada  N/A  RR : ... ... x/mnt 5. … …
Keluhan Lain: … …

Diagnosa Keperawatan:
1. Penurunan curah jantung b/d … … …
2. Perfusi jaringan tidakefektif b/d …
3. Kelebihan / kekurangan volume
cairan b/d … …
CIRCULATION

Nadi :  Teraba  Tidak teraba Kriteria Hasil : … … …

Intervensi :
TD/BP : 1. Lakukan CPR dan Defibrilasi
2. Kontrol perdarahan
Sianosis :  Ya  Tidak
3. Pemberian cairan intravena
Akral dingin  Akral Hangat  4. Mengator posisi (Shock position)
5. Monitor Vital sign
CRT :  ≤3 detik  > 3 detik
6. Kolaborasi Medikasi
Pendarahan :  Ya  Tidak ada 7. Monitor irama jantung
Keluhan Lain: ... ... (EKG)
.

DISABILITY Diagnosa Keperawatan:

1. Gangguan perfusi serebral b/d … …
2. Risiko cidera...
3. Intoleransi aktivias b/d (pindah ke C)
PRIMER SURVEY

Respon : Alert  Verbal  Pain  Unrespon Kriteria Hasil : … … …

Kesadaran :  CM  Delirium  Somnolen 
Intervensi :
Coma , .............................................. 1. Berikan posisi head up 30 derajat
2. Periksa kesadaran dan GCS tiap 5
GCS :  Eye ...  Verbal ...  Motorik ...
menit
Refleks Pupil :  Isokor  Unisokor  Pinpoint  3. … … …
4. … … …
Medriasis
5. … … …
Keluhan Lain : … …

TAMBAHKAN PANDUAN GCS

EXPOSURE Diagnosa Keperawatan:

1. Kerusakan integritas jaringan b/d …
……
2. Kerusakan mobilitas fisik b/d … … …
3. Hipotermi b/d
4.
 Deformitas :  Ya  Tidak Kriteria Hasil : … … …
Contusio :  Ya  Tidak
Abrasi :  Ya  Tidak Intervensi :
Penetrasi : Ya  Tidak 1. Perawatan luka
Laserasi : Ya  Tidak 2. Heacting
Edema : Ya  Tidak 3. … … …
Luas Luka: 4. … … …
Keluhan Lain:
……

Diagnosa Keperawatan:
1. Regimen terapiutik inefektif b/d … …
…
ANAMNESA 2. Nyeri Akut b/d … … …
3. … … …

Riwayat Penyakit Saat Ini : … … … Kriteria Hasil : … … …

Intervensi :
1. … … …
2. … … …

Alergi :

Medikasi :
SECONDARY SURVEY

Riwayat Penyakit Sebelumnya:

Makan Minum Terakhir:

Even/Peristiwa Penyebab:

Tanda Vital :
BP : N: S: RR :
PEMERIKSAAN FISIK Diagnosa Keperawatan:
1. … … …
2. … … …

Kepala dan Leher: Kriteria Hasil : … … …

Inspeksi ... ...
Intervensi :
1. … … …
2. … … …

Palpasi ... ...

 Dada:
Inspeksi ... ...

Palpasi ... ...

SECONDARY SURVEY

Perkusi ... ...

Auskultasi ... ...

Abdomen:
Inspeksi ... ...

Palpasi ... ...

Perkusi ... ...

Auskultasi ... ...

Pelvis:
Inspeksi ... ...

Palpasi ... ...

Ektremitas Atas/Bawah:
Inspeksi ... ...

Palpasi ... ...

Punggung :
 Diagnosa Keperawatan:
PEMERIKSAAN DIAGNOSTIK 1. … … …
2. … … …
 RONTGEN  CT-SCAN  USG  EKG Kriteria Hasil : … … …
 ENDOSKOPI
Intervensi :
 Lab Darah : 1. … … …
2. … … …
 AGD:
 Lain-lain, ... ...

Hasil :

TERAPI/MEDIKASI:

Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan : NAMA TERANG :
 KEMENTERIAN KESEHATAN R.I
POLITEKNIK KESEHATAN JAMBI
JURUSAN KEPERAWATAN
JL.DR. TAZAR KELURAHAN BULURAN KENALI KEC. TELANAIPURA JAMBI

RESUME PRAKTIK KLINIK KEPERAWATAN GAWAT DARURAT

TEMPAT PRAKTIK :............................................................................

NAMA KLIEN : ............................................................................
NO REGISTER : ............................................................................
UMUR : ............................................................................
JENIS KELAMIN : ............................................................................
DIAGNOSA MEDIS : ............................................................................

KELUHAN UTAMA :

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HASIL PEMERIKSAAN FISIK (INSPEKSI, PALPASI, PERKUSI , AUSKULTASI):

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HASIL PEMERIKSAAN PENUNJANG (RADIOGRAFI, HEMATOLOGI, KIMIA

DARAH, CT SCAN, MRI, USG, EKG, DLL):

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TERAPI MEDIS:

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TINDAKAN (KEPERAWATAN DAN MEDIS):

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EVALUASI

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