SEKOLAH TINGGI ILMU KESEHATAN

NGUDIA HUSADA MADURA

Program Study S1 Ilmu Keperawatan - Program Praktek Profesi Ners
JL. RE Martadinata No.45 Telp. (031) 3061522 – Bangkalan-Madura 69116.
E-mail: nhm_stikes@yahoo.co.id

FORMAT PENGKAJIAN
KEPERAWATAN GAWAT DARURAT
(Ruang:................RSUD............................)
I. Identitas klien

1. Nama :
2. No RM :
3. Usia :
4. Jenis kelamin :
5. Alamat :
6. Pendidikan :
7. Agama :
8. Status :
9. Suku/ Bangsa :
10. Tanggal MRS :
11. Tanggal pengkajian :
12. Ruangan :
13. Diagnosa medis :

II. Identitas penanggung jawab

1. Nama :
2. Umur :
3. Jenis kelamin :
4. Agama :
5. Suku :
6. Hub dengan klien :
7. Alamat :
III. Keluhan utama :
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IV. Riwayat penyakit sekarang
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V. Riwayat penyakit dahulu
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 VI. Primary Survey
A: Airway ( Jalan nafas )
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B: Breathing ( Pernafasan )
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C: Circulation ( Sirkulasi )
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D: Disability ( Ketidakmampuan )
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E: Exposure ( Paparan )
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VII. Pemeriksaan Head to toe

NO ITEM YANG DIAMATI :

1. KEADAAN UMUM
2. KESADARAN
3. TANDA – TANDA TD :
VITAL SUHU :
RR :
NADI :
4. INTEGUMENT/ INSPEKSI
KULIT 1. Kulit :
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2. Rambut :
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3. Kuku :
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PALPASI
1. Kulit :
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2. Rambut :
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3. Kuku :
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5. KEPALA INSPEKSI :
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PALPASI :
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6. WAJAH INSPEKSI
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PALPASI
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7. MATA INSPEKSI
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REFLEK KORNEA :
REFLEK PUPIL :
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8. HIDUNG INSPEKSI :
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PALPASI :
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9. MULUT INSPEKSI :
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10. TELINGA INSPEKSI :
1. Amati telinga luar :
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2. Telinga bag dalam:
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PALPASI :
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11. LEHER INSPEKSI :
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PALPASI :
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12. DADA / THORAK a. PARU-PARU
INSPEKSI :
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PALPASI :
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PERKUSI:
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AUSKULTASI :
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b. JANTUNG
INSPEKSI :
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PALPASI :
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PERKUSI :
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AUSKULTASI :
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13. ABDOMEN INSPEKSI :

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AUSKULTASI :
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PERKUSI:
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PALPASI:
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14. EKSTRIMITAS ATAS

INSPEKSI :
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PALPASI:
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BAWAH
INSPEKSI :
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PALPASI:
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15. GENETALIA PRIA :
INSPEKSI :
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PALPASI :
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WANITA :

INSPEKSI :
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16. ANUS INSPEKSI :
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PALPASI :
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 ANALISA DATA
Nama Pasien : No.RM :
Umur : Ruang :
NO DATA (DS/DO) PROBLEM ETIOLOGI
 DIAGNOSA KEPERAWATAN
Nama Pasien : No.RM :
Umur : Ruang :
NO DIAGNOSA KEPERAWATAN
 INTERVENSI KEPERAWATAN
Nama Pasien : No.RM :
Umur : Ruang :
Diagnosa :

No Tanggal SLKI SIKI

 IMPLEMENTASI KEPERAWATAN
Nama Pasien : No.RM :
Umur : Ruang :
Tanggal/jam No. Dx Tindakan Keperawatan Paraf
 EVALUASI KEPERAWATAN

Nama Pasien : No.RM :

Umur : Ruang :
Tanggal/jam No. Dx Evaluasi (SOAP) Paraf