AKADEMI KEPERAWATAN BAHRULULUM JOMBANG

TAMBAKBERAS–JOMBANG–JAWATIMUR
SK MENDIKNAS : 223 / D / O / 2001
REKOMENDASI MENKES RI. NO. KS. 01. SJ.1067/2001

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT PADA ORANG

DEWASA

No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...
IDENTITAS

Nama : Jenis Kelamin : L/P Umur:

Agama : Status Perkawinan : Pendidikan :
Pekerjaan : Sumber informasi : Alamat :

TRIAGE P1 P2 P3 P4
GENERAL IMPRESSION
Keluhan Utama :

Mekanisme Cedera :

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...
Diagnosa Keperawatan:
AIRWAY Inefektif airway b/d … … …
Jalan Nafas :  Paten  Tidak Paten Kriteria Hasil : … … …
Obstruksi :  Lidah  Cairan  Benda Asing  N/A
Intervensi :
Suara Nafas : Snoring Gurgling 1. Manajemen airway;headtilt-chin lift/jaw
thrust
Keluhan Lain: ... ...
2. Pengambilan benda asing dengan
forcep
3. … …
4. … …
SURVEY
PRIMER

Diagnosa Keperawatan:
1. Inefektif pola nafas b/d … … …
BREATHING 2. Kerusakan pertukaran gas b/d … …
…

Gerakan dada:  Simetris  Asimetris Kriteria Hasil : … … …

Irama Nafas :  Cepat  Dangkal  Normal
Intervensi :
Pola Nafas :  Teratur  Tidak Teratur 1. Pemberian terapi oksigen … …
Retraksi otot dada :  Ada  N/A ltr/mnt, via… …
2. Bantuan dengan Bag Valve Mask
Sesak Nafas :  Ada  N/A  RR............x/mnt 3. Persiapan ventilator mekanik 4.
Keluhan Lain: … … ……
5. … …

Diagnosa Keperawatan:
1. Penurunan curah jantung b/d … … …
CIRCULATION 2. Inefektif perfusi jaringan b/d … … …

Nadi :  Teraba  Tidak teraba Kriteria Hasil : … … …

Sianosis :  Ya  Tidak Intervensi :
 AKADEMI KEPERAWATAN BAHRULULUM JOMBANG
TAMBAKBERAS–JOMBANG–JAWATIMUR
SK MENDIKNAS : 223 / D / O / 2001
REKOMENDASI MENKES RI. NO. KS. 01. SJ.1067/2001

CRT :  < 2 detik  > 2 detik 1. Lakukan CPR dan Defibrilasi

2. Kontrol perdarahan
Pendarahan :  Ya  Tidak ada 3. ……
Keluhan Lain: ... ... 4. ……

DISABILITY Diagnosa Keperawatan:

1. Inefektif perfusi serebral b/d … … …
2. Intoleransi aktivias b/d … … …
3. … … …

Respon : Alert  Verbal  Pain  Unrespon Kriteria Hasil : … … …

Kesadaran :  CM  Delirium  Somnolen  ... ... Intervensi :
... 1. Berikan posisi head up 30 derajat
2. Periksa kesadaran dann GCS tiap 5
GCS :  Eye ...  Verbal ...  Motorik ...
SURVEY
PRIMER

menit
Pupil :  Isokor  Unisokor  Pinpoint  Medriasis 3. … … …
4. … … …
Refleks Cahaya:  Ada  Tidak Ada 5. … … …
Keluhan Lain : … …

Diagnosa Keperawatan:
1. Kerusakan integritas jaringan b/d …
……
EXPOSURE 2. Kerusakan mobilitas fisik b/d … … …
3. … … …

Deformitas :  Ya  Tidak Kriteria Hasil : … … …

Contusio :  Ya  Tidak
Abrasi :  Ya  Tidak Intervensi :
Penetrasi : Ya  Tidak 1. Perawatan luka
Laserasi : Ya  Tidak 2. Heacting
Edema : Ya  Tidak 3. … … …
Keluhan Lain: 4. … … …
……

Diagnosa Keperawatan:
1. Regimen terapiutik inefektif b/d … …
…
ANAMNESA
SECONDAR

2. Nyeri Akut b/d … … …

3. … … …

Riwayat Penyakit Saat Ini : … … … Kriteria Hasil : … … …

Y

Intervensi :
1. … … …
2. … … …
Alergi :

Medikasi :
 AKADEMI KEPERAWATAN BAHRULULUM JOMBANG
TAMBAKBERAS–JOMBANG–JAWATIMUR
SK MENDIKNAS : 223 / D / O / 2001
REKOMENDASI MENKES RI. NO. KS. 01. SJ.1067/2001
Jl. KH. Abdul Wahab Chasbullah Gg. IV Tambakberas Jombang 61451 Telp/Fax. (0321) 876040

Riwayat Penyakit Sebelumnya:

Makan Minum Terakhir:

Even/Peristiwa Penyebab:

Tanda Vital :
BP : N: S: RR :
PEMERIKSAAN FISIK Diagnosa Keperawatan:
1. … … …
2. … … …
Kepala dan Leher: Kriteria Hasil : … … …
Inspeksi ... ... Intervensi :
Palpasi ... ... 3. … … …
4. … … …
Dada:
Inspeksi ... ...
Palpasi ... ...
Perkusi ... ...
SECONDARY SURVEY

Auskultasi ... ...

Abdomen:
Inspeksi ... ...
Palpasi ... ...
Perkusi ... ...
Auskultasi ... ...
Pelvis:
Inspeksi ... ...
Palpasi ... ...
Ektremitas Atas/Bawah:
Inspeksi ... ...
Palpasi ... ...
Punggung :
Inspeksi ... ...
Palpasi ... ...
Neurologis :
 AKADEMI KEPERAWATAN BAHRULULUM
JOMBANG
TAMBAKBERAS–JOMBANG–JAWATIMUR
SK MENDIKNAS : 223 / D / O / 2001
REKOMENDASI MENKES RI. NO. KS. 01. SJ.1067/2001

Diagnosa Keperawatan:
PEMERIKSAAN DIAGNOSTIK 1. … … …
2. … … …
 RONTGEN  CT-SCAN  USG  EKG Kriteria Hasil : … … …
 ENDOSKOPI  Lain-lain, ... ...
Intervensi : 1.
Hasil : ………
2. ………

Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan : NAMA TERANG :

ASSESMENT: Berdasarkan triase pasien tergolong pada Prioritas .....................

NURSING CARE PLANTS:

1. Diagnosa Keperawatan
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2. Intervensi Keperawatan

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 AKADEMI KEPERAWATAN BAHRULULUM
JOMBANG
TAMBAKBERAS–JOMBANG–JAWATIMUR
SK MENDIKNAS : 223 / D / O / 2001
REKOMENDASI MENKES RI. NO. KS. 01. SJ.1067/2001

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3. Implementasi Keperawatan
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 AKADEMI KEPERAWATAN BAHRULULUM
JOMBANG
TAMBAKBERAS–JOMBANG–JAWATIMUR
SK MENDIKNAS : 223 / D / O / 2001
REKOMENDASI MENKES RI. NO. KS. 01. SJ.1067/2001

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5. Evaluasi Keperawatan
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 AKADEMI KEPERAWATAN BAHRULULUM
JOMBANG
TAMBAKBERAS–JOMBANG–JAWATIMUR
SK MENDIKNAS : 223 / D / O / 2001
REKOMENDASI MENKES RI. NO. KS. 01. SJ.1067/2001

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Terapi Obat Yang Diberikan:

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Mahasiswa,

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