AKADEMI KEPERAWATAN

PEMERINTAH KABUPATEN KONAWE

Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

1. PENGKAJIAN KEPERAWATAN GAWAT DARURAT & DI RUANG ICU

Tgl/ jam : ………………………………… No. RM :……………………………..
Triage : P1/P2/P3 Diagnosis Medis: ……………………………..
Transportasi : ambulan/mobil pribadi/lain-lain:…………………………...........................................
Nama :......................................................... Jenis Kelamin :.................................................
IDENTITAS

Umur : ........................................................ Alamat : ...........................................................

Agama : ...................................................... Status Perkawinan : .........................................
Pendidikan : ............................................... Sumber Informasi : ..........................................
Pekerjaan : .................................................. Hubungan : ......................................................
Suku / bangsa : ........................................... Keluhan Utama : ..............................................
Jalan nafas :  Paten  Tidak Paten
Obstruksi :  Lidah  Cairan  Benda Asing  Tidak ada
AIRWAY

 Muntahan  Darah  Oedema

Suara nafas :  Snoring  Gurgling  Stridor  Tidak ada

Keluhan lain : ............................................................................................................................

Masalah keperawatan : ...............................................................................................................
Nafas  Spontan  Tidak Spontan
Gerakan dinding dada  Simetris  Asimetris
Irama nafas  Cepat  Dangkal  Normal  Ada
Pola nafas  Teratur  Tidak Teratur
BREATHNG

Jenis  Dispneu  Kusmaul  Cyene Stoke  Lain..

Suara nafas  Vesikuler  Stridor  Wheezing  Ronchi
Cuping hidung  Ada  Tidak ada
Retraksi otot bantu nafas  Ada  Tidak ada
RR: .........x/mnt
Pernafasan  Dada  Perut
Keluhan lain : .............................................................................................................................
Masalah keperawatan : ...............................................................................................................
Nadi  Teraba  Tidak Teraba N: .........x/mnt
Tekanan Darah ...................mmHg 
Pucat  Ya  Tidak 
Sianosis  Ya  Tidak 
CRT  < 2 dtk  > 2 dtk
Akral  Hangat  Dingin
Perdarahan  Ada  Tidak ada 
 Lokasi .................................. 
 Jumlah ..............................cc 
Turgor  Elastis  Lambat
Diaphoresis  Ya  Tidak
Riwayat kehilangan cairan berlebih  Diare  Muntah  Luka Bakar
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

Keluhan lain :..............................................................................................................................

CUL
CIR

Masalah keperawatan : ..............................................................................................................

Kesadaran  Composmentis  Delirium  Somnolen  Apatis  Koma
GCS  Eye  Verbal  Motorik
Pupil  Isokor  Unisokor  Pinpoint  Midriasis
Refleks Cahaya  Ada  Tidak Ada
Refleks Fisiologis  Patela (+/-) ...................
DISABILITY

Refleks Patologis  Babinzky (+/-) ...................

 Kernig (+/-) ...................
 Lain.................
Kekuatan Otot

Keluhan lain :..............................................................................................................................

Masalah keperawatan : ...............................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

 Deformitas  Ya  Tidak  Lokasi ...............................

 Contusio  Ya  Tidak  Lokasi ...............................
 Abrasi  Ya  Tidak  Lokasi ...............................
 Penetrasi  Ya  Tidak  Lokasi ...............................
 Laserasi  Ya  Tidak  Lokasi ...............................
 Edema  Ya  Tidak  Lokasi ...............................
EXPOSURE

 Luka Bakar  Ya  Tidak  Lokasi ...............................

 Jika terdapat Grade .............%  Lokasi ...............................
Luka/ vulnus,  Luas Luka ......................
kaji:  Warna Dasar Luka ......................
 Kedalaman Luka ......................

Lain-lain: ....................................................................................................................................
Masalah Keperawatan : ..............................................................................................................
....................................................................................................................................................
Monitoring jantung :  sinus bradikardi  sinus takikardi
Saturasi oksigen : ............... %
Kateter urine :  ada  tidak ada
Pemasangan NGT :  Ada, warna cairan lambung :.................................
FIVE INTERVENTION

 Tidak
Terapi Medis:
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Lain-lain: ....................................................................................................................................
Masalah keperawatan :................................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

Pemeriksaan Laboratorium:

Nyeri :  Ada  Tidak Ada

Problem : .......................................................................................................................
GIVE COMFORT

Qualitas/ quantitas : ...................................................................................................................

Regio : .......................................................................................................................................
Skala : ........................................................................................................................................
Timing : .....................................................................................................................................
Lain-lain : ..................................................................................................................................
Masalah keperawatan : ..............................................................................................................
....................................................................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

Keluhan utama :
....................................................................................................................................................
Mekanisme cidera (trauma) :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Sign / tanda gejala :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
HISTORY

Alergi :
....................................................................................................................................................
Medication / pengobatan :
....................................................................................................................................................
....................................................................................................................................................
Post Medical History :
....................................................................................................................................................
....................................................................................................................................................
Last Oral Intake:
....................................................................................................................................................
Event Leading Injury:
....................................................................................................................................................
....................................................................................................................................................
(fokus pemeriksaan pada daerah trauma / sesuai kasus nontrauma )
HEAD TO

Kepala dan wajah :

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

Leher :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Dada :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Abdomen dan pinggang :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
HEAD TO TOE

Pelvis dan perineum :

TOE

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

Ekstremitas :
 Atas:
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
 Bawah
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
Masalah keperawatan :
....................................................................................................................................................
....................................................................................................................................................
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

Jejas :  Ada  Tidak

....................................................................................................................................................
Deformitas :  Ada  Tidak
INSPECTION BACK/ POSTERIOR SURFACE

....................................................................................................................................................
Tenderness :  Ada  Tidak
....................................................................................................................................................
Crepitasi :  Ada  Tidak
....................................................................................................................................................
Laserasi :  Ada  Tidak
....................................................................................................................................................
Lain-lain:.....................................................................................................................................
Masalah keperawatan : ..............................................................................................................
....................................................................................................................................................

2. Klasifikasi Data

3. Analisah Data
 AKADEMI KEPERAWATAN
PEMERINTAH KABUPATEN KONAWE
Jl. Sultan Hasanuddin No.111 Kelurahan Lalosabila Kec. Wawotobi, Telp (0408) 2421459

4. Diagnosa Keperawatan

5. Rencana Asuhan Keperawatan

6. Implementasi

7. Evaluasi