Form Asesmen Awal Igd 2.docx

RUMAH SAKIT ISLAM GONDANGLEGI Jl.Hayam Wuruk No.66 Gondanglegi Malang 65174 Telp.(0341)879047-879879-878593 Fax.(0341)878593 Email:[email protected]

LABEL IDENTITAS

STATUS PENGKAJIAN GAWAT DARURAT Unjungan Pasien Baru Lama Warganegara WNI WNA Agama:..................................................... Pendidikan :................................................................................................................ Cara Datang / Rujuk: Sendiri Rujukan................................................... Tiba di RSI Gondanglegi ........................................................................................................................................ Tanggal : ................................................. ........................................................................................................................................ Jam datang : .................................WIB ...................................................................................................................................... .. Jam dilayani : .................................WIB ..... Jam periksa : .................................WIB Transportasi waktu datang : Ambulan 118 Ambulance lain Kendaraan lain Jenis kasus : Bedah Non Bedah Kebidanan Anak Resusitasi : Ya Tidak Penyebab cidera / keracunan : Kecelakaan Lalu Lintas Kecelakaan Rumah Tangga Kecelakaan Kerja ........................................................ Tempat Kejadiaan : ................................................................................................................ / ................. Jam : ........................WIB Aktivitas :.................................................................................................................................................................................... Keluhan Utama:......................................................................................................................................................................................... Tanda-tanda vital : GCS : E:........V:........M:........ Pupil :................mm/.............mm Reflek Ca haya :.............. / ................. TD : ................/............mmHg Nadi :.................x/menit, reguler / irreguler Suhu :................. °C RR : ................. x/menit SpO2:............. % Akral: hangat / dingin / kering / basah CRT: < 2 dtk / > 2 dtk ALERGI TERHADAP :............................................................................................................................................................................ Assesmen psikologi Takut terhadap terapi/pembedahan *) Takut terhadap lingkungan rumah sakit Senang Marah/tegang Sedih Menangis Cemas Rendah diri Tidak mampu menahan diri Gelisah Mudah tersinggung Tenang .................................... *Bila ada gangguan,lakukan pengkajian Restrain SKALA TRIASE P1 P2 P3 P0 GCS <8 8 s/d < 13 13 Kejang  Airway  Gasping  Jalan nafas bebas  Suara nafas  Stridor  Nafas spontan abnormal Breathing  RR  < 40  18-20 dewasa  40  SPO2  85%-90%  < 85%   94%  Retraksi  Ringan  Berat Circulation  Tekanan darah  Sistolik < 80  Sistolik > 200  Dalam batas normal  Nadi  Lemah/hilang  < 50 / > 150  CRT  < 2 detik   2detik  Akral  Dingin  Dingin / hangat  Suhu  >40%  40 dg kejang  Gr I  Luka bakar  Gr 2A/2B > 30%  Gr 2A/2B < 30%  Gr 3> 5%  Trauma listrik Assesmen Nutrisi  BB :...........................Kg/gr TB;............................. Lingkar kepala: ......................cm (khusus pediatrik)  Gangguan pemenuhan kebutuhan nutrisi : Ya Tidak  Apakah pasien mengalami penurunan/peningkatan*)BB yang tidak direncanakan/tidak diinginkan? Ya,...........................Kg/gram*) Tidak Assesmen sosial dan ekonomi  Pekerjaan ..........................................................  Peran dalam keluarga Penanggung jawab ekonomi Kepala Keluarga  Budaya keluarga yang mempengaruhi pola kesehatan Tidak ada Ada Jelaskan..................................................................................................................................................................................... Suku Bangsa Jawa Madura ............................ ............................................ Adat /Budaya yang mempengaruhi pola kesehatan..................................................................................................................  Pembiayaan saat di rumah sakit Bayar Sendiri Asuransi Swasta Perusahaan BPJS ...........................  Pengaruh terhadap ekonomi saat pasiwen dirawat Ada .................................... Tidak ada Petugas Triase

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PENGKAJIAN KEPERAWATAN (Diisi Oleh Perawat) Auto anamnese Nama : Hubungan: 1. Informasi didapat dari Hetero anamnese Jalan tanpa bantuan 2. Cara Masuk Jalan dengan bantuan: Kursi roda Tempat tidur dorong lainnya........................... Riwayat Penyakit Sekarang .................................................................................................................................................................................................................... .................................................................................................................................................................................................................... ........................................................................................................................................................................ ............................................. .................................................................................................................................................................................................................. .. ..................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... Riwayat Penyakit Dahulu Riwayat Pengobatan Obat diteruskan Waktu pemberian No Nama obat Cara pemberian Ket terakhir Ya Tidak

Skala nyeri ( Beri tanda √ ) INTENSITAS NYERI “WONG BAKER FACES PAIN RATING SCALE” DAN “NUMERIC RATING SCALE” (NRS) UNTUK ANAK ≥ 6 TAHUN DAN DEWASA

Pengkajian Wajah Kaki Aktivitas Menangis Bersuara

Skala FLACC(Face,Legs,Activity,Cry,Consolability)untuk anak < 6 tahun 0 1 2 Tersenyum/tidak ada exspresi Terkadang menangis/menarik Sering menggetarkan khusus diri dagu&mengatupkan rahang Gerakan normal/relaksasi Tidak tenang/tegang Kaki dibuata menendang/menarik diri Tidur,posisi normal,mudah Gerarakan Melengkungkan bergerak menggeliat,berguling,kaku punggung/kaku/menghentak Tidak menangis(bangun/tidur) Menegerang,merengek-rengek Menangis terusmenerus,terhisak,menjerit Bersuara normal/tenang Tenang bila dipeluk,digendong Sulit untuk menenangkan atau diajak bicara

Nilai

Total skor Pengkajian fungsi: Aktivitas sehari-hari Mandiri Dengan bantuan Pengkajian dan intervensi resiko jatuh (Get Up and Go Test) a. Cara berjalan pasien  Tidak seimbang/sempoyongan/limbung Ya Tidak  Jalan dengan menggunakan alat bantu(kruk,kursi roda,tripot,orang lain) Ya Tidak b. Menopang saat akan duduk  Tampak memegang pinggiran kursi/meja/benda lain sebagai penopang saat akan Ya Tidak Hasil : Tidak resiko (tidak ditemukan a& b) Tidak beresiko = tidak ada tindakan Resiko rendah (ditemukan salah satu dari a/b) Resiko Rendah = Edukasi Resiko Tinggi (ditemukan a&b) Resiko tinggi = Pasang pitakuning dan edukasi Pengkajian resiko dekubitus  Apakah pasien menggunakan kursi roda atau mebutuhkan bantuan? Ya Tidak  Apakah ada inkontensia urine atau alvi ? Ya Tidak  Apakah ada riwayat dekubitus atau riwayat dekubitus? Ya Tidak  Apakah pasien di atas 65 tahun ? Ya Tidak Khusus anak  Apakah ekstremitas dan badan tidak sesuai dengan usia perkembangannya? Ya Tidak Apabila salah satu jawaban adalah “ya”.maka lakukan edukasi pencegahan dekubitus Status kehamilan Tidak hamil Hamil,Gravida :.........................Para:..........................Abortus:...........................HPHT:...................... Perawat yang mengkaji

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III.PENGKAJIAN MEDIS Pemeriksaan doter,jam:...............................WIB Subyektif: .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. Obyektif: .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. Pemeriksaan penunjang EKG :............................................................................................................................. ................................................. Radiologi :.............................................................................................................................................................................. Laboratorium :.............................................................................................................................................................................. Assessment Dignosa kerja :............................................................................................................................ ............................................. ................................................................................................................................................................................................................. Diagnosa banding:............................................................................................................................ ............................................... .................................................................................................................................................................................................................. Planning :Penatalaksanaan/Pengobatan/Rencana tindakan .................................................................................................................................................................................................................. ................................................................................................................................................................. ................................................. ............................................................................................................................................................................................................... ... .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. ....................................................................................................................................... ........................................................................... ..................................................................................................................................................................................... ............................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. Tulbak

Edukasi Tgl/ jam

Materi edukasi

Uraian tambahan

Evaluasi

Tanda tangan Pasien/klg

Edukator

Penyakit,penyebab,tanda,dan gejala(DX:................................) Hasil pemeriksaan Tindakan medis Komplikasi Farmasi Manajemen nyeri ................................................... ................................................... ................................................... Gondanglegi,...................................... ....................................... ( Tanda tangan dan nama dokter)

MASALAH KEPERAWATAN DAN EVALUASI MASALAH KEPERAWATAN Penuruann kesadaran Kejang Ketidak efektifan/bersihan jalan nafas Sesak Nyeri Gangguan hemodinamika Gangguan integritas kulit Gangguan keseimbangan cairan dan elektrolit Peningkatan ushu tubuh ................................................................................... PEMBERIAN OBAT/INFUS Jam Nama obat/infus Dosis

TINDAKAN Jam

EVALUASI

Rute

Diperiksa oleh

Tindakan

Diberikan oleh

Nama &TTD

KONDISI PASIEN SAAT PINDAH/PULANG DARI UGD Tanda-tanda vital : GCS : E:........V:........M:........ Pupil :................mm/.............mm Reflek Cahaya :.............. / ................. TD : ................/............mmHg Nadi :.................x/menit, reguler / irreguler Suhu :................. °C RR : ................. x/menit SpO2:............. % Akral: hangat / dingin / kering / basah CRT: < 2 dtk / > 2 dtk TINDAK LANJUT Boleh pulang Menolak MRS MRS di ruang................................................................................... Dirujuk, ke.................................................Alasan dirujuk:.................................................. ............................................................. Meninggal DOA DOR Jam.............................WB Pendidikan kesehatan pasien pulang: Makan.minum obat teratur Jaga kebersihan luka Diet .................................................................... Nama /Tanda Tangan Dokter Nama /Tanda Tangan Perawat

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....................................................... Nama /Tanda Tangan Keluarga

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