FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Nama Mahasiswa :
Tempat Praktek :
Tanggal Praktek :
Tanggal Pengkajian :

A. Identitas Pasien
Nama :…………………………………………….
Tanggal Lahir :…………………………………………….
Umur :…………………………………………….
Agama :…………………………………………….
Jenis Kelamin :…………………………………………….
Status :…………………………………………….
Pendidikan :…………………………………………….
Pekerjaan :…………………………………………….
Suku Bangsa :…………………………………………….
Alamat :…………………………………………….
Tanggal Masuk :…………………………………………….
Tanggal Pengkajian :…………………………………………….
No. Register :…………………………………………….
Diagnosa Medis :…………………………………………….

B. Identitas Penanggung Jawab

Nama :…………………………………………….
Umur :…………………………………………….
Hub. Dengan Pasien :…………………………………………….
Pekerjaan :…………………………………………….
Alamat :…………………………………………….

Status Kesehatan
A. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini):

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2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini:

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3) Upaya yang dilakukan untuk mengatasinya:

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B. Satus Kesehatan Masa Lalu

1) Penyakit yang pernah dialami:
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2) Pernah dirawat:
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3) Alergi:

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4) Kebiasaan (merokok/kopi/alkohol dll):

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C. Riwayat Penyakit Keluarga

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D. Diagnosa Medis dan therapy

Diagnosa :
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Therapy : ..............................................................................................................................
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Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

A. Pola Persepsi dan Manajemen Kesehatan
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B. Pola Nutrisi-Metabolik
Sebelum sakit          :...................................................................................................
Saat sakit                 :...................................................................................................

C. Pola Eliminasi
1. BAB
1) Sebelum sakit         : ...................................................................................................
2) Saat sakit                : ...................................................................................................
2. BAK
1) Sebelum sakit         : ...................................................................................................  
2) Saat sakit                : ...................................................................................................

D. Pola aktivitas dan Latihan
1. Aktivitas
Kemampuan 0 1 2 3 4
Perawatan Diri
Makan dan minum
Mandi
Toileting
Berpakaian
Berpindah
0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total

2. Latihan
1) Sebelum sakit         : ...................................................................................................
2) Saat sakit                 : ...................................................................................................

E. Pola kognitif dan Persepsi:

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F. Pola Persepsi-Konsep diri:
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G. Pola Tidur dan Istirahat:

1) Sebelum sakit         : .........................................................................................................
2) Saat sakit                 : .........................................................................................................

H. Pola Peran-Hubungan:
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I. Pola Seksual-Reproduksi
1) Sebelum sakit         : .........................................................................................................
2) Saat sakit                 : .........................................................................................................

J. Pola Toleransi Stress-Koping:

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K. Pola Nilai-Kepercayaan
1) Sebelum sakit         :  .........................................................................................................
2) Saat sakit                 : .........................................................................................................

Pengkajian Fisik
1. Keadaan umum:
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2. Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma

GCS: Verbal: Psikomotor: Mata :

3. Tanda-tanda Vital : Nadi =             ……… , Suhu =………….  , TD =…………, RR =………

4. Kenyamanan/Nyeri:
P: .............................................................................................................................................
Q: .............................................................................................................................................
R: .............................................................................................................................................
S: .............................................................................................................................................
T: .............................................................................................................................................

5. Pemeriksaan Fisik
1) Kepala  dan leher:

Kepala dan Rambut:

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Mata:
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Hidung:
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Mulut dan Lidah:

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Telinga:
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Leher:

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2) Pemeriksaan  Dada/ Pernafasan  :

Paru
Inspeksi:
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Palpasi:
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Perkusi:
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Auskultasi:
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Jantung
Inspeksi :
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Palpasi:
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Perkusi:
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Auskultasi:
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Payudara dan ketiak   :

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3) Pemeriksaan sistem pencernaan dan Status Nutrisi:

BB sesudah sakit:
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BB sebelum sakit:
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TB:
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IMT:
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Diet:
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4) Pemeriksaan Abdomen
Abdomen   
Inspeksi :
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Palpasi:
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Perkusi:
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Auskultasi:
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5) Pemeriksaan sistem persyarafan:

Memori:
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Perhatian:
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Bahasa:
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Orientasi:
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Saraf sensori:
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Refleks fisiologis:
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Refleks patologis:
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Pemeriksaan saraf kranial:

N 1 (olfaktorius):
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N II (optikus):
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N III (okulomotorius):
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N IV (troklearis):
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N V (trigeminus):
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N VI (abdusen):
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N VII (facialis):
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 N VIII (vestibulotroklearis):
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N IX (glosofaringeus):
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N X (vagus):
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N XI (assesorius):
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N XII (hipoglosus):
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6) Pemeriksaan system perkemihan

Genetalia:
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Urin:
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Balance Cairan:
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7) Pemeriksaan sistem muskuloskeletal dan integumen

a. Integumen :
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b. Ekstremitas     :
Atas:
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Bawah:
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c. Kekuatan otot:
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8) Pemeriksaan system endokrin:

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Pemeriksaan Penunjang
1. Data laboratorium yang berhubungan
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2. Pemeriksaan radiologi
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3. Hasil konsultasi
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4. Pemeriksaan penunjang diagnostik lain

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A. ANALISA DATA
DATA Etiologi MASALAH

B. Daftar  Diagnosa Aktual/Resiko/Promosi Kesehatan

NO TANGGAL / DIAGNOSA KEPERAWATAN Ttd
JAM
DITEMUKAN
1

Dst
C. Intervensi  Keperawatan
No Diagnosa (SDKI) Tujuan dan Kreteria Intervensi (SIKI)
Hasil (SLKI)
1 D..... L..... I.....

Gejala dan tanda mayor Ekspektasi : Observasi:

Subjektif:

Objektif: Kreteria Hasil: Terapeutik:

Gejala dan tanda Minor Edukasi:

Subjektif:

Objektif: Kolaborasi:

2 D..... L..... I.....

Faktor Resiko: Ekspektasi : Observasi:

Kreteria Hasil: Terapeutik:

Edukasi:

Kolaborasi:
3 D..... L..... I.....

Gejala dan tanda mayor Ekspektasi : Observasi:

Subjektif:

Objektif: Kreteria Hasil: Terapeutik:

 Gejala dan tanda Minor Edukasi:
Subjektif:

Objektif: Kolaborasi:

D. Luaran Keperawatan
No. Dx Luaran Keperawatan
Ekspektasi Kreteria Hasil
Setelah dilakukan Intervensi
Keperawatan selama ……… maka
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dengan kreteria hasil :
- …………………………………………
- …………………………………………
- …………………………………………

Setelah dilakukan Intervensi

Keperawatan selama ……… maka
………………………………………………
dengan kreteria hasil :
- …………………………………………
- …………………………………………
- …………………………………………

Setelah dilakukan Intervensi

Keperawatan selama ……… maka
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dengan kreteria hasil :
- …………………………………………
- …………………………………………
- …………………………………………

      
E. Evaluasi Keperawatan
Hari/Tgl Diagnosa
Evaluasi (SOAP) TTd
Jam Keperawatan
S:

O:

A:

P:

S:

O:

A:

P:

S:

O:

A:

P: