STIKes WN
I. Identitas Mahasiswa
Nama MHS :
NIM :
Kelompok :
Tgl Praktek :
Kardiovaskuler Muskuloskeletal
Normal Normal
Pernafasan Genitourinaria
Normal Normal
37
36
35
Kesadaran
Irama EKG
Nyeri
CVP
Line 2
Line 3
Line 4
Enteral
Total
Output NGT
Urine
BAB
Drain
Total
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BAGIAN KGD FORMAT PENGKAJIAN KEPERAWATAN GAW AT DARURAT
STIKes WN
I. Identitas Mahasiswa
Nama MHS :
NIM :
Kelompok :
Tgl Praktek :
TRIAGE: P1 P2 P3 P4
P : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
Q : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
R : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
S : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
T : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
BREATHING
Sesak, dengan :
Aktifitas ....................................................................................
Tanpa aktifitas .........................................................................
Nafas cuping hidung ...............................................................
Menggunakan otot tambahan .................................................
Frekuensi
Irama:
Teratur .....................................................................................
Tidak teratur ............................................................................
Kedalaman
Dalam ..................................................................................
Dangkal ................................................................................
Cepat ....................................................................................
Batuk:
Produktif ...............................................................................
Non produktif ........................................................................
Bunyi nafas tambahan:
Ronkhi ..................................................................................
Crackles/celah,retak ............................................................
Wheezing/Mencuit2 ..............................................................
CIRCULATION
Kesadaran : .............................................................................
Sirkulasi perifer : .......................................................................
Nadi : ........................
Irama :........................
Teratur /Tidak teratur : .........................................................
Denyut:
Lemah ..................................................................................
Kuat .....................................................................................
Tidak kuat .............
Tekanan darah :.........
Ekstremitas : ..............
Hangat ..................
Dingin ..................
Warna kulit :
Cyanosis ..............
Pucat ....................
Kemerahan ...........
DISABILITY
Pemeriksaan neurologis singkat
Respon:
Alert/perhatian ......................................................................
Voice respons/respon terhadap suara .................................
Pain respons/respon terhadap nyeri .....................................
Unresponsive/tidak berespon ...............................................
Reaksi pupil ..........................................................................
EKSPOSURE/ENVIRONMENT/EVENT
Deformitas : Ya Tidak
Contusio : Ya Tidak
Abrasi : Ya Tidak
Penetrasi : Ya Tidak
Laserasi : Ya Tidak
Edema : Ya Tidak
Keluhan Lain:
…………..…………………………………………………………..
.................................................................................
V. PENGKAJIAN SEKUNDER
Riwayat kesehatan sekarang ....................................................
Riwayat kesehatan keluarga ....................................................
Anamnesa singkat (AMPLE) ......................................................
Allergies.............................
Medikasi ............................
Nyeri ..................................
Terakhir kali makan ...........
Event of injury/penyebab injury..........
- Telinga :
- Hidung :
- Mulut :
- Leher
Deviasi/simetns, cedera servikal ..........................................
Kelenjar tiroid .......................................................................
Kelenjar limfe .......................................................................
Trakea ..................................................................................
JVP .......................................................................................
- Dada
I :
P :
P :
A :
- Abdomen :
I :
A :
P :
P :
- Ekstermitas/musculoskeletal
Rentang gerak.................................................................
Kekuatan otot ..................................................................
Deformitas.......................................................................
Kontraktur .......................................................................
Edema ............................................................................
Nyeri................................................................................
Krepitasi ..........................................................................
- Kulit/integumen:
Turgor:
Baik .................
Buruk ..............
Sedang ...........
Mukosa:
Lembab ...........
Kering..............
Kulit:
Bintik merah ...
Lesi .................
Suhu .....................
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