Form Dokumentasi Askep Gawat Darurat.docx

FORM DOKUMENTASI ASKEP GAWAT DARURAT (DI IGD) IDENTITAS KLIEN Nama

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No. Register

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Usia

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Jenis Kelamin

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Tanggal masuk

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Diagnosa Medik

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RIWAYAT KESEHATAN SEKARANG

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PRAKTIK PKK II – UNIMUS 2018 | FORM DOKUMENTASI ASKEP GAWAT DARURAT (DI IGD)

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PENGKAJIAN FOKUS, DIAGNOSA KEPERAWATAN, DAN INTERVENSI PENGKAJIAN

Airways (jalan nafas) Sumbatan: ( ) Benda asing. ( ) Darah ( ) Bronkospasme ( ) Sputum ( ) Lendir Breathing (Pernafasan) Sesak, dengan: ( ) aktifitas ( ) tanpa aktifitas ( ) menggunakan otot tambahan Frekuensi: ...................... Irama: ( ) teratur, ( ) tdk teratur Kedalaman: ( ) dalam, ( ) dangkal Batuk: ( ) Produktif, ( ) Non produktif Sputum: ( ) ada. ( ) tidak ada Bunyi nafas: ( ) ronchi ( ) creakles ( ) wheezing ( ) snoring Circulation (sirkulasi) Sirkulasi perifer: Frekwensi nadi: Irama nadi: ( ) teratur ( ) tidak teratur Denyut nadi: ( ) lemah ( ) kuat ( ) tak kuat TD: Ektremitas: ( ) hangat ( ) dingin Warna kulit:

DIAGNOSA KEP

JAM

INTERVENSI & TINDAKAN KEP

PARAF

( ) aktual ( ) resiko Bersihan Jalan nafas tidak efektif bd. ............ ....................................... ...................................... ( ) aktual ( ) resiko Pola Nafas tidak Efektif b/d ..............................

( ) aktual ( ) resiko Gangguan pertukaran gas b/d. ...................... .................................... ( ) Aktual ( ) Resiko Penurunan curah jantung b.d. ........................... .................................. ..................................

PRAKTIK PKK II – UNIMUS 2018 | FORM DOKUMENTASI ASKEP GAWAT DARURAT (DI IGD)

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PENGKAJIAN

DIAGNOSA KEP

( ) cyanosis ( ) pucat ( ) kemerahan Pengisian kapiler: ....... dtk Edema: ( ) ya, area…………………. ( ) tidak Eliminasi dan Cairan BAK: x/hari Jumlah: ( ) sedikit ( ) banyak ( ) sedang Warna: ( ) kuning jernih ( ) Kuning kental ( ) merah ( ) putih Rasa sakit: ( ) ya ( ) tidak Keluhan sakit pinggang: ( ) ya ( ) tidak BAB: x/hari. Diare: ( ) ya ( ) tidak ( ) berdarah ( ) cair ( ) berlendir Abdomen: ( ) Datar ( )Cembung ( ) Cekung ( ) elastis ( ) lembek ( ) kembung ( ) asites Turgor ( ) baik ( ) buruk ( ) sedang Mukosa: ( ) lembab ( ) kering Kulit: ( ) Bintik merah ( ) Jejas ( ) Lecet lecet ( ) Luka Suhu : ......oC Lidah kotor: ( ) ya ( ) tdk Nyeri:

( ) Aktual ( ) Resiko Perubahan perfusi jaringan:......................... b.d. ................................ ....................................... .......................................

JAM

INTERVENSI & TINDAKAN KEP

PARAF

( ) Aktual ( ) Resiko Gg keseimbangan Cairan dan elektrolit: kurang / lebih b.d. ........................... .................................. ..................................

( ) aktual ( ) resiko Gg integritas jaringan b.d.................................. ........................................ ........................................

PRAKTIK PKK II – UNIMUS 2018 | FORM DOKUMENTASI ASKEP GAWAT DARURAT (DI IGD)

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PENGKAJIAN

( ) Ya, ( ) ulu hati ( ) kuadran ka. ( ) menyebar ( ) tidak Integumen (kulit) Luka: ( ) ya ( ) tidak Dalam: ( ) ya ( ) tidak Perdarahan: ( ) ya ( ) tidak Dissability: Tingkat kesadaran: ( ) cm ( ) apatis ( ) somnolen ( ) sopor ( ) soporocoma ( ) koma Pupil: ( ) isokor ( ) unisokor ( ) moosis ( ) midriasis Reaksi terhadap cahaya: Ka: ( ) positif ( ) Negatif Ki : ( ) positif ( ) Negatif GCS: E M V= Terjadi ( ) kejang ( ) pelo ( ) kelumpuhan/kelemahan ( ) mulut mencong ( ) afasia ( ) disathria Nilai kekuatan otot: Refleks Babinsky : Patella : Bisep/trisep: Brudzinsky :

DIAGNOSA KEP

JAM

INTERVENSI & TINDAKAN KEP

PARAF

( ) aktual ( ) resiko Gg perfusi jaringan cerebral b.d.............. ................................... ................................... ...................................

PRAKTIK PKK II – UNIMUS 2018 | FORM DOKUMENTASI ASKEP GAWAT DARURAT (DI IGD)

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