PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Tgl/Jam : ......................................... No. RM : .........................................

Ruangan : ......................................... Diagnosis Medis : .........................................
Nama/Inisial : ...................................... Jenis Kelamin : ......................................
Umur : .................................... Status Perkawinan : ......................................
Agama : ..................................... Sumber Informasi : ......................................
IDENTITAS

Pendidikan : ..................................... Hubungan : ......................................

Pekerjaan : .......................................
Suku/bangsa : ..........................................
Alamat : ....................................................................................

Keluhan utama saat MRS :

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Keluhan utama saat pengkajian :
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RIWAYAT SAKIT DAN KESEHATAN

Riwayat penyakit saat ini :

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Riwayat alergi :
............................................................................................................................................
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Riwayat pengobatan :
...........................................................................................................................................
...........................................................................................................................................
Riwayat penyakit sebelumnya dan riwayat penyakit keluarga :
............................................................................................................................................
.............................................................................................................................................
 Jalan nafas ( ) paten ( ) tidak paten
Obstruksi ( ) lidah ( ) cairan ( ) benda asing ( ) tidak ada
( ) muntahan ( ) darah ( ) odema
Suara nafas ( ) snoring ( ) gurgling ( ) Stridor ( ) tidak ada
Nafas ( ) spontan ( ) tidak spontan
Gerakan dinding dada ( ) simetris ( ) asimetris
Irama nafas ( ) cepat ( ) dangkal ( ) normal
Pola nafas ( ) teratur ( )tidak teratur
Jenis ( ) dispnoe ( ) kusmaul ( ) cyene stoke ( ) lain………….
Suara nafas ( ) vesikuler ( ) stidor ( ) whezing ( ) ronchi
Sesak nafas ( ) ada ( ) tidak ada
Cuping hidung ( ) ada ( ) tidak ada
Retraksi otot bantu nafas ( ) ada ( ) tidak ada
BREATHNG

Pernafasan ( ) pernafasan dada ( ) pernafasan perut

Batuk ( ) ya ( ) tidak ada
Sputum ( ) ya, warna ............... konsistensi .................... volume ...........bau ..............
( ) tidak ada
RR : ............... x/mnt
Alat bantu nafas ( ) OTT ( ) ETT ( ) trakeostomi ( ) ventilator ,
keterangan .........................................................................................................................................
.
Oksigenasi .... lt/mnt ( ) nasal kanul ( ) simple mask ( ) non RBT mask
( ) RBT mask ( ) tidak ada
Lain : .......................................................................

Masalah keperawatan :

Nadi : ( ) teraba ( ) tidak teraba ( ) N:...........x/mnt

Tekanan darah : ........... mmHg
Pucat : ( ) ya, ( ) tidak
Sianosis : ( ) ya, ( ) tidak
CRT : ( ) <2 dtik ( ) > 2 detik
Akral : ( ) hangat ( ) dingin ( ) S: ........ oC
Perdarahan : ( ) ya, lokasi.............. ..................................... jumlah .........cc ( ) tidak
BLOOD

Turgor : ( ) elastis ( ) lambat

Diaphoresis : ( ) ya, ( ) tidak
Riwayat kehilangan cairan berlebihan : ( ) diare ( ) muntah ( ) luka bakar
IVFD : ( ) ya ( ) tidak , jenis cairan ..............
Lain:................

Masalah keperawatan :
 Kesadaran: ( ) composmentis ( ) delirium ( ) somnolen ( ) apatis ( ) koma
GCS: ( ) eye........ ( ) verbal ....... ( ) motorik...........
Pupil : ( ) isokor ( ) unisokor ( ) pinpoint ( ) medriasis
Refleks cahaya : ( ) ada ( ) tidak ada
Refleks fisiologis : ( ) patela (+/-) ( ) lain-lain ............
Reflek patologis : ( ) babinzky ( +/-) ( ) kerning ( +/-) ( ) lain-lain………
Refleks pada bayi : ( ) refleks rooting (+/-) ( ) refleks moro (+/-)
(khusus PICU/NICU ) ( ) refleks sucking (+/-) ( ) lain-lain……
Bicara : ( ) lancar ( ) cepat ( ) lambat
Tidur malam : …… jam tidur siang : .......... jam
Ansietas : ( ) ada ( ) tidak ada
Psiko-sosio-spiritual:
BRAIN

a. Orang yang paling dekat

b. Hubungan dengan teman dan lingkungan sekitar
Konsep diri:
a. Gambaran diri:
b. Ideal diri:
c. Harga diri:
d. Peran:
e. Identitas diri:
Lain-lain : ....................

Masalah keperawatan :
 Nyeri penggang : ( ) ada ( ) tidak ada
BAK : ( ) lancar ( ) inkontenensia ( ) anuri
Nyeri BAK : ( ) ada ( ) tidak ada
Frekuensi BAK :............. warna : .................. darah : ............... ( ) ada ( ) tidak ada
Kateter : ( ) ada ( ) tidak ada, urine out put ............

Hitung jumlah cairan untuk pasien pada:

Hari 1:
Hari 2:
Target urine output pasien:

Balance cairan 24 jam sebelum pengkajian:

1. INPUT:
BLADDER

a. IVFD:
b. Obat:
c. Minum (jumlah dan jenis):
2. OUTPUT:
a. Urine:
b. Muntah:
c. IWL:
3. BALANCE CAIRAN: Input-(Output+IWL):

Lain-lain:..................

Masalah keperawatan :

TB : ......... cm BB : ............. Kg
Nafsu makan : ( ) mual ( ) muntah ( ) sulit menelan
Makan : frekuensi ............x/mnt. Jumlah :.........porsi
Minum : frekuensi ............x/mnt. Jumlah : .........cc/hr
Perut kembung: ( ) ya ( ) tidak ada
BOWEL

BAB : ( ) teratur ( ) tidak

Frekuensi BAB : ............ x/mnt. Konsistensi :................... warna :............ darah (+/-)
Lendir (+/-)
Lain:.........

Masalah keperawatan :
 Nyeri : ( ) ada ( ) tidak ada
Problem : ............................................................................................................................
Qualitas/quantitas : .............................................................................................................
Regio : ................................................................................................................................
Skala :..................................................................................................................................
Timing :...............................................................................................................................
Kekuatan otot : ...................................................................................................................
.............................................................................................................................................
BONE (Muskuloskeletal dan Integument )

Deformitas : ( ) ya ( ) tidak ( ) lokasi :................................................................

..............................................................................................................................................
Contusio : ( ) ya ( ) tidak ( ) lokasi :........................................................................
.............................................................................................................................................
Abrasi : ( ) ya ( ) tidak ( ) lokasi :............................................................................
..............................................................................................................................................
Pentrasi : ( ) ya ( ) tidak ( ) lokasi :..........................................................................
.............................................................................................................................................
Laserasi: ( ) ya ( ) tidak ( ) lokasi :...........................................................................
..............................................................................................................................................
Edema: ( ) ya ( ) tidak ( ) lokasi :.............................................................................
..............................................................................................................................................
Luka bakar: ( ) ya ( ) tidak ( ) lokasi .......................................................................
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Grade : .............. %
 Jika ada luka/vulnus , kaji:
Luas luka:.............................................................................................................................
Warna dasar luka:................................................................................................................
Kedalaman :.........................................................................................................................

Aktivitas : ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4
BONE (Muskuloskeletal dan Integument )

Makan/minum: ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( )4
Mandi : ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4
Toileting : ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4

Berpakaian : ( )0( )1( )2( )3( )4

Mobilisasi di tempat tidur : ( )0( )1( )2( )3( )4

Berpindah : ( )0( )1( )2 ( )3 ( )4

Ambulasi : ( )0( )1 ( )2( )3( )4

Keterangan: ........................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Lain-lain:..............................................................................................................................

Masalah keperawatan :
 (fokus pemeriksaan pada daerah trauma/ sesuai kasus non trauma)
Kepala wajah :
Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.

Leher :
HEAD TO TOE

Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.

Dada :
Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.

Abdomen dan pinggang :

Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.
HEAD TO TOE

Pelvis dan perineum :

Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.

Masalah keperawatan :
 Ekstremitas :
Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
HEAD TO TOE

Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.

Masalah keperawatan :
TEST DIAGNOSTIK

Hasil laboratorium : tgl ...................

DAN TERAPI

.............................................................................................................................................
.............................................................................................................................................
Terapi medis saat ini : tgl .................
DIAGNOSTI

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TEST

Analisis Data
No. Hr/tgl/jam Data Subjektif Data Objektif Etiologi Masalah
Keperawatan

Diagnosa Keperawatan (Tulis yang lengkap berdasarkan prioritas masalah keperawatan)

Intervensi Keperawatan
No. Hr/tgl/jam Diagnosa Tujuan Keperawatan Intervensi
Keperawatan Goal Objective Outcome Keperawatan
Label NOC Label NIC

Implementasi Keperawatan
No. Hr/Tgl Diagnosa Keperawatan Jam Implementasi Evaluasi Tanda
Keperawatan Keperawatan Tangan
(tulis apa yang S:
 dikerjakan, O:
kerjakan apa yang A:
ditulis) P:

Catatan Perkembangan Hari 1

No. Hr/Tgl Diagnosa Jam Evaluasi Keperawatan Tanda
Keperawatan Tangan
S:
O:
A:
P:
I: (tulis apa yang dikerjakan,
kerjakan apa yang ditulis)
E:

Catatan Perkembangan Hari 2

No. Hr/Tgl Diagnosa Jam Evaluasi Keperawatan Tanda
Keperawatan Tangan
S:
O:
A:
P:
I: (tulis apa yang dikerjakan,
kerjakan apa yang ditulis)
E:

Catatan Perkembangan Hari 3

No. Hr/Tgl Diagnosa Jam Evaluasi Keperawatan Tanda
Keperawatan Tangan
S:
O:
A:
P:

LAPORAN ASUHAN KEPERAWATAN GAWAT DARURAT

PADA ...................
DENGAN ......................................... DI RUANG ...................................
RS……………………………………………….
TANGGAL ................................
 OLEH:
……………………………………….
NIM

PROGRAM PROFESI NERS

UNIVERSITAS CITRA BANGSA KUPANG
2019

ASUHAN KEPERAWATAN ...................................................................

Nama Mahasiswa :
NIM :
Ruangan : No. reg :
Tanggal dikaji : Pkl. :
PENGKAJIAN
A. Identitas
Nama : Tgl. MRS :
Umur : Jam :
Suku/bangsa : Diangnosa :
Agama :
Alamat :
Pekerjaan :
Pendidikan :
Alasan MRS :

B. Nursing history

C. Observasi dan pemeriksaan fisik

1. Keadaan umum

2. Tanda – tanda vital

3. Primary Survey:
Airway :......................................................................................................
Breathing :......................................................................................................
Circulation :......................................................................................................
Disability :......................................................................................................
Exposure :…………………………………………………………………………………………………………
Foley Cateter :......................................................................................................
Gastric Tube :.....................................................................................................
Heart Rate :.....................................................................................................
4. Masalah keperawatan: ............................................................................................
5. Secondary Survey
a. Riwayat Penyakit
Sign & Simptom :................................................................................................
Alergi :................................................................................................
........................................................................................................................................
Medikasi :................................................................................................
........................................................................................................................................
Post Illnes :................................................................................................
 ........................................................................................................................................
Last Meal :................................................................................................
........................................................................................................................................
Event/Environtment :................................................................................................
........................................................................................................................................
b. Pemeriksaan Fisik Head to Toe: .....................................................................................
........................................................................................................................................
........................................................................................................................................

6. Pemeriksaan penunjang :..............................................................................................

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7. Analisis Data (Buatkan dalam tabel)...........................................................................
8. Diagnosa Keperawatan: ................................................................................................
.....................................................................................................................................
9. Intervensi Keperawatan (Buatkan dalam tabel)
10. Implementasi Keperawatan (buatkan dalam tabel)
11. Terapi: .........................................................................................................................
.....................................................................................................................................
12. Evaluasi: .......................................................................................................................
.....................................................................................................................................

Mahasiswa,
Format Laporan Pendahuluan
A. Konsep Dasar Penyakit
1. Pengertian
2. Etiologi
3. Patofisiologi (Pathway)
4. Manifestasi klinis
5. Komplikasi
6. Pemeriksaan penunjang
7. Penatalaksanaan (farmakologi, non farmakologi)
B. Konsep Dasar Asuhan Keperawatan
1. Pengkajian keperawatan
a. Anamnesa:
b. Pemeriksaan fisik: (jika pada masalah keperawatan pada pathway ditegakkan sesuai
B1-B6 atau per sistem, maka pada pemeriksaan fisik disesuaikan dengan pathway)
2. Diagnosa keperawatan (tegakkan diagnosa keperawatan sesuai dengan pathway)
3. Intervensi keperawatan (buatkan dalam tabel sesuai dengan diagnosa keperawatan yang
ditegakkan)
4. Implementasi keperawatan
5. Evaluasi keperawatan