Format Askep Gadar 7b.docx

FORMAT ASUHAN KEPERAWATAN DI RUANG IGD ............................................ Tanggal Pengkajian: .................. Pukul:.................... A. PENGKAJIAN Anamnesa (wawancara) 1. Identitas pasien Nama

: ....................................................................................................

Umur

: ....................................................................................................

Jenis kelamin

: ....................................................................................................

Alamat

: ....................................................................................................

No. Telp

: ....................................................................................................

Pekerjaan

: ....................................................................................................

Agama

: ....................................................................................................

Diagnosa medis

: ....................................................................................................

No. Register

: ....................................................................................................

2. Keluhan utama (PQRST) ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ 3. Riwayat alergi ................................................................................................................................................ ............................................................................................................................................... 4. Riwayat pengobatan terakhir/obat yang telah atau sedang dikonsumsi korban ................................................................................................................................................ ............................................................................................................................................... 5. Riwayat penyakit terdahulu ................................................................................................................................................ ................................................................................................................................................ 6. Riwayat makanan yang dikonsumsi terakhir ................................................................................................................................................ ............................................................................................................................................... 7. Kondisi lingkungan yang berhubungan dengan kejadian perlukaan atau trauma ................................................................................................................................................ ...............................................................................................................................................

8. Primary Survey: a) Airway (jalan nafas): -

Look :.....................................................................................................

-

Listen :.....................................................................................................

-

Feel

:.....................................................................................................

b) Breathing (pernafasan) -

Look (gerakan dada) : ............................................................................

-

Frekuensi nafas

: ............................................................................

-

Sianosis

: ............................................................................

c) Circulation (sirkulasi) -

Nadi arteri carotis

: ............................................................................

-

Nadi arteri radialis

: ............................................................................

-

Frekuensi Nadi

: ............................................................................

-

Akral

: ............................................................................

-

Perdarahan

: ............................................................................

d) Disability -

Respon verbal : .......................................................................................

-

Respon pain

: .......................................................................................

e) Exposure (paparan) -

Kepala belakang

: ............................................................................

-

Punggung

: ............................................................................

-

Panggul

: ............................................................................

-

Kaki

: ............................................................................

9. Secondary survey (pemeriksaan head to toe): a) Kepala

: ....................................................................................................

b) Leher

: ....................................................................................................

c) Bahu

: ....................................................................................................

d) Dada

: ....................................................................................................

e) Perut

: ....................................................................................................

f) Genetalia : .................................................................................................... g) Punggung : .................................................................................................... h) Panggul

: ....................................................................................................

i) Tangan

: ....................................................................................................

j) Kaki

: ....................................................................................................

B. Diagnosa keperawatan (diagnosa keperawatan yang bersifat/berkaitan dengan masalah gawat darurat, bukan diagnosa KMB atau KDM): .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... C. Perencanaan dan Implementasi (tuliskan goal dan Intervensi) .......................................................................................................................................... .......................................................................................................................................... ..........................................................................................................................................

o Tindakan Keperawatan No. Tanggal Jam/waktu

Tindakan

Evaluasi setelah tindakan

Catatan: Dokumetasi/catatan tindakan keperawatan gawat darurat berisikan catatan dalam bentuk tindakan keperawatan mandiri, tindakan dan terapi medis serta pemeriksaan penunjang: laboratorium dan radiologi, dan lain-lain....

D. Evaluasi Airway: ................................................................................................................................................ ................................................................................................................................................ Breathing: ................................................................................................................................................ ................................................................................................................................................ Circulation: ................................................................................................................................................ ............................................................................................................................................... Disability: ................................................................................................................................................ ............................................................................................................................................... Eksposure: ................................................................................................................................................ ...............................................................................................................................................

Tanda Tangan, Nama Terang

(.......................)