ASUHAN KEPERAWATAN GAWAT DARURAT DAN KRITIS

PADA ……………………………….
DI RUANG ………. RSU dr.H KOESNADI BONDOWOSO

Oleh :

ROMELIA APRILIANTI

NIM. 2031800105

PROGRAM STUDI PENDIDIKAN PROFESI NERS

FAKULTAS KESEHATAN – UNIVERSITAS NURUL JADID

PAITON PROBOLINGGO

2022
 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):
.............................................................................................................................................
.............................................................................................................................................

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

.............................................................................................................................................
.............................................................................................................................................

3) Upaya yang dilakukan untuk mengatasinya:

.............................................................................................................................................
.............................................................................................................................................

B. Satus Kesehatan Masa Lalu

1) Penyakit yang pernah dialami:
.............................................................................................................................................
.............................................................................................................................................

2) Pernah dirawat:
.............................................................................................................................................
3) Alergi:
.............................................................................................................................................
.............................................................................................................................................

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

.............................................................................................................................................
.............................................................................................................................................
C. Riwayat Penyakit Keluarga
.............................................................................................................................................
.............................................................................................................................................

D. Diagnosa Medis dan therapy

Diagnosa :
.............................................................................................................................................

Therapy : .........................................................................................................................
....................
.............................................................................................................................................
.............................................................................................................................................

Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

A. Pola Persepsi dan Manajemen Kesehatan
.............................................................................................................................................

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:
.............................................................................................................................................
.............................................................................................................................................
F. Pola Persepsi-Konsep diri:
.............................................................................................................................................
.............................................................................................................................................
G. Pola Tidur dan Istirahat:
1) Sebelum sakit         : .....................................................................................................
2) Saat sakit                 :......................................................................................................

H. Pola Peran-Hubungan:
.............................................................................................................................................
.............................................................................................................................................
I. Pola Seksual-Reproduksi
1) Sebelum sakit       : .....................................................................................................
2) Saat sakit              :.....................................................................................................
3)
J. Pola Toleransi Stress-Koping:
............................................................................................................................................

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

Pengkajian Fisik
1. Keadaan umum:
.............................................................................................................................................

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:

.............................................................................................................................................
Mata:
.............................................................................................................................................

Hidung:
.............................................................................................................................................

Mulut dan Lidah:

.............................................................................................................................................
Telinga:
.............................................................................................................................................
Leher:
.............................................................................................................................................

2) Pemeriksaan  Dada/ Pernafasan  :

Paru
Inspeksi:
.............................................................................................................................................
Palpasi:
.............................................................................................................................................
Perkusi:
.............................................................................................................................................
Auskultasi:
.............................................................................................................................................
Jantung
Inspeksi :
.............................................................................................................................................
Palpasi:
.............................................................................................................................................
Perkusi:
.............................................................................................................................................
Auskultasi:
.............................................................................................................................................
Payudara dan ketiak   :
.............................................................................................................................................
3) Pemeriksaan sistem pencernaan dan Status Nutrisi:
BB sesudah sakit:
.......................................................................................................................................
BB sebelum sakit:
......................................................................................................................................

TB:
......................................................................................................................................
IMT:
......................................................................................................................................
Diet:
.......................................................................................................................................

4) Pemeriksaan Abdomen
Abdomen   
Inspeksi :
.......................................................................................................................................
Palpasi:
.......................................................................................................................................
Perkusi:
.......................................................................................................................................
Auskultasi:
.......................................................................................................................................

5) Pemeriksaan sistem persyarafan:

Memori:
.......................................................................................................................................
Perhatian:
.......................................................................................................................................
Bahasa:
.......................................................................................................................................
Orientasi:
.......................................................................................................................................
Saraf sensori:
.......................................................................................................................................
Refleks fisiologis:
.......................................................................................................................................

Refleks patologis:
.......................................................................................................................................

Pemeriksaan saraf kranial:

N 1 (olfaktorius):
.......................................................................................................................................

N II (optikus):
.......................................................................................................................................

N III (okulomotorius):
.......................................................................................................................................

N IV (troklearis):
.......................................................................................................................................

N V (trigeminus):
.......................................................................................................................................

N VI (abdusen):
.......................................................................................................................................

N VII (facialis):
.......................................................................................................................................

N VIII (vestibulotroklearis):
.......................................................................................................................................

N IX (glosofaringeus):
.......................................................................................................................................

N X (vagus):
.......................................................................................................................................

N XI (assesorius):
.......................................................................................................................................

N XII (hipoglosus):
.......................................................................................................................................
 6) Pemeriksaan system perkemihan

Genetalia:
.......................................................................................................................................

Urin:
.......................................................................................................................................

Balance Cairan:
.......................................................................................................................................

7) Pemeriksaan sistem muskuloskeletal dan integumen

a. Integumen :
.................................................................................................................................
.

b. Ekstremitas     :
Atas:
......................................................................................................................................

Bawah:
......................................................................................................................................

c. Kekuatan otot:
.................................................................................................................................
.

8) Pemeriksaan system endokrin:

.......................................................................................................................................
.......................................................................................................................................

Pemeriksaan Penunjang
1. Data laboratorium yang berhubungan
...................................................................................................................................................
...................................................................................................................................................
.

2. Pemeriksaan radiologi
...................................................................................................................................................
...................................................................................................................................................

3. Hasil konsultasi
...................................................................................................................................................
...................................................................................................................................................

4. Pemeriksaan penunjang diagnostik lain

...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
A. ANALISA DATA
DATA Etiologi MASALAH
A. ANALISA DATA
DATA Etiologi MASALAH
A. ANALISA DATA
DATA Etiologi MASALAH
B. Daftar  Diagnosa Aktual/Resiko/Promosi Kesehatan
N TANGGAL / DIAGNOSA KEPERAWATAN Ttd
O JAM
DITEMUKA
N
 C. Intervensi  Keperawatan
No Diagnosa (SDKI) Tujuan dan Intervensi (SIKI)
Kreteria Hasil
(SLKI)
1 D..... L..... I.....

Gejala dan tanda mayor Ekspektasi : Observasi:

Subjektif:

Objektif: Kreteria Hasil:

Terapeutik:

Gejala dan tanda Minor

Subjektif: Edukasi:

Objektif:
 Kolaborasi:

N Diagnosa (SDKI) Tujuan dan Intervensi (SIKI)

o Kreteria Hasil
(SLKI)
2 D..... L..... I.....

Gejala dan tanda mayor Ekspektasi : Observasi:

Subjektif:

Objektif: Kreteria Hasil:

Terapeutik:

Gejala dan tanda Minor

Subjektif: Edukasi:

Objektif:
 Kolaborasi:

N Diagnosa (SDKI) Tujuan dan Intervensi (SIKI)

o Kreteria Hasil
(SLKI)
3 D..... L..... I.....

Gejala dan tanda mayor Observasi:

Subjektif: Ekspektasi :

Objektif:

Kreteria Hasil: Terapeutik:

Gejala dan tanda Minor

Subjektif: Edukasi:

Objektif:
 Kolaborasi:

D. Luaran Keperawatan
Luaran Kreteria Hasil
No. Dx Ekspektasi
Keperawatan
Setelah dilakukan Intervensi
Keperawatan selama ……… maka
………………………………………
………
dengan kreteria hasil :
D.Luaran Keperawatan
Luaran Kreteria Hasil
No. Dx Ekspektasi
Keperawatan
Setelah dilakukan Intervensi
Keperawatan selama ……… maka
………………………………………
………
dengan kreteria hasil :
D.Luaran Keperawatan
Luaran Kreteria Hasil
No. Dx Ekspektasi
Keperawatan
Setelah dilakukan Intervensi
Keperawatan selama ……… maka
………………………………………
………
dengan kreteria hasil :
E. Evaluasi Keperawatan
Hari/Tgl Diagnosa
Evaluasi (SOAP) TTd
Jam Keperawatan
A. Evaluasi Keperawatan
Hari/Tgl Diagnosa
Evaluasi (SOAP) TTd
Jam Keperawatan
A. Evaluasi Keperawatan
Hari/Tgl Diagnosa
Evaluasi (SOAP) TTd
Jam Keperawatan