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FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT DI IGD I.
PENGKAJIAN Nama Pengkaji
:……………………………....
Tanggal Pengkajian
: ……………………………....
Jam Pengkajian
: ……………………………....
A. Biodata Pasien Nama
:………………………………….....................................
Jenis Kelamin
: …………………………………....................................
Pendidikan
: …………………………………....................................
Pekerjaan
: …………………………………....................................
Usia
: …………………………………....................................
Status Pernikahana
: …………………………………....................................
No. RM
: …………………………………....................................
Diagnosa Media
: …………………………………....................................
Alamat
: …………………………………....................................
B. Biodata Penanggung Jawab Nama
: …………………………………....................................
Jenis Kelamin
: …………………………………....................................
Pendidikan
: …………………………………....................................
Pekerjaan
: …………………………………....................................
Hubungan dengan klien : ………………………………….................................... : …………………………………....................................
Alamat
C. Pengkajian Primer 1) Airway (Jalan Nafas) Sumbatan : (
) benda asing
(
) bronkospasme
(
) sputum
(
) darah
(
) lendir
(
) bebas / tanpa
(
) gurgling
(
)stridor
sumbatan Suara Nafas : (
) snoring
Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
2) Breathing ( Pernafsan ) Sesak, dengan (
) aktivitas
(
) tanpa aktivitas
(
) menggunakan otot
tambahan Frekuensi
:……………..x/menit
Irama
:(
) teratur
(
) tidak teratur
Kedalaman
:(
) dalam
(
) dangkal
Batuk
:(
) produktif
(
) non produktif
Sputum
:(
) ada
(
) tidak ada
Warna
: …………………………………………………………
Konsistensi
: …………………………………………………………
Bunyi Nafas
:
(
) ronchi
(
(
)……………………….
) wheezing
(
) crakels
Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
3) Circulation ( Sirkulasi ) Sirkulasi perifer : Nadi
: ………x/menit
Irama
:(
) teratur
(
) tidak teratur
Denyut
:(
) kuat
(
) lemah
TD
:…………mmHg
Ekstermitas
:(
(
) dingin
) hangat
Warna Kulit
:(
) sianosis
(
) pucat
(
) kemerahan
Nyeri dada
:(
) ada
(
) tidak ada
) menyebar
(
) seperti ditusuk-tusuk
Karakteristik nyeri dada : (
) menetap
(
(
) seperti ditimpa benda berat
CRT
:(
) < 2 detijk
(
) > 2 detik
Edema
:(
) iya
(
) tidak
(
) tungkai
Lokasi Edema : (
) muka
(
) tangan atas
(
)
) banyak
(
)
(
) putih
anasarka Eliminasi dan cairan : BAK
: ………………………x/menit
Jumlah
:(
) sedikit
Warna
:(
) kuning jernih (
) kuning kental
Rasa Sakit
:(
) iya
) tidak
BAB
: ………………………x/hari
(
sedang
(
Diare : (
) iya
(
) berlendir
(
) tidak
(
) berdarah
(
) cair
(
) buruk
Turgor
:(
) baik
(
) sedang
Mukosa
:(
) lembab
(
) kering
Suhu
: …………0C
Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
4) Disability Tingkat Kesadaran : (
) composmentis
(
) apatis
(
) somnolen
(
) stupor
(
) soporocoma
(
) koma
Pupil : (
) isokor
(
) midrasis
(
) anisokor
(
) negative
(
) negative
(
) miosis
Reaksi terhadap cahaya : Kanan ; (
) positif
Kiri (
:
) positif
GCS
:
Eve
Verbal
Motorik
Terjadi : (
) kejang
(
) pelo
(
)
(
) afasia
(
) disatria
kelumpuhan/kelemahan (
) mulut mencong
(
) berlendir
Nilai Kekuatan otot :
Refleks: Babinsky
: …………………………………………………………
Patella
: …………………………………………………………
Bisep/trisep
: …………………………………………………………
Brudynskt
: …………………………………………………………
Masalah Keperawatan
:
………………………………………………………………………………… …………………...……………………………….…………………………… ……………..…………………….…………………………………………… ……………….…..…………………….……………………………………… 5) Eksposure ………………………………………………………………………………… …………………...……………………………….…………………………… ……………..…………………….…………………………………………… ……………….…..…………………….………………………………………
Masalah Keperawatan : ………………………………………………………………………………… …………………...……………………………….…………………………… ……………..…………………….…………………………………………… ……………….…..…………………….………………………………………
D. PENGKAJIAN SEKUNDER 1) Keluhan Utama
: ………………………………………………………
Nyeri (bila ada nyeri) : P
: ………………………………………………………………………
Q
: ………………………………………………………………………
R
: ………………………………………………………………………
S
: ………………………………………………………………………
T
: ………………………………………………………………………
2) Alergi terhadap obat, makanan tertentu
: ………………………………
………………………………………………………………………………… ………………………………………………………………………………… 3) Medikasi/ pengobatan terakhir
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………….. 4) Event/ injury/ penyebab injury
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 5) Pengalaman atau pembedahan
:
………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
6) Riwayat penyakit sekarang
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 7) Riwayat penyakit Dahulu
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 8) Pemeriksaan Fisik a. Kepala ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………
b. Leher ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… c. Dada ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… d. Abdomen ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………
e. Ekstermitas Luka
: (
) iya
(
) tidak
Dalam
: (
) iya
(
) tidak
Perdarahan
: (
) iya
(
) tidak
Deformitas
: ........................................................................................
Kontraktur
: ........................................................................................
Nyeri
: ........................................................................................
Krepitasi
: ........................................................................................
f. Kulit / integument Mukosa
:(
) lembab
(
) kering
Kulit
:(
) bintik merah
(
) jejas
(
) luka
(
) lecet
E. PEMERIKSAAN PENUNJANG Hari/Tanggal
Jenis Pemeriksaan
Hasil
Nilai Normal
F. ANALISA DATA NO
DATA
ETIOLOGI
PROBLEM
II.
DIAGNOSA KEPERAWATAN 1. …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... 2. …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... 3. …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... ……………………………………………………………………………………....
III.
PERENCANAAN Diagnosa Keperawatan : …………………………………………………………………………………….........……………………………………………………… …………………………………………………………………………………….........……………………………………………………… …………………………………………………………………………………….........……………………………………………………… No
Tujuan dan Kriteria Hasil
Intervensi
Rasional
IV.
IMPLEMENTASI DAN EVALUASI No
Diagnosa Keperawatan
Jam
Implementasi
Paraf
Evaluasi
PENGKAJIAN Nama Pengkaji
:……………………………....
Tanggal Pengkajian
: ……………………………....
Jam Pengkajian
: ……………………………....
A. Biodata Pasien Nama
:………………………………….....................................
Jenis Kelamin
: …………………………………....................................
Pendidikan
: …………………………………....................................
Pekerjaan
: …………………………………....................................
Usia
: …………………………………....................................
Status Pernikahana
: …………………………………....................................
No. RM
: …………………………………....................................
Diagnosa Media
: …………………………………....................................
Alamat
: …………………………………....................................
B. Biodata Penanggung Jawab Nama
: …………………………………....................................
Jenis Kelamin
: …………………………………....................................
Pendidikan
: …………………………………....................................
Pekerjaan
: …………………………………....................................
Hubungan dengan klien : ………………………………….................................... : …………………………………....................................
Alamat
C. Pengkajian Primer 1) Airway (Jalan Nafas) Sumbatan : (
) benda asing
(
) bronkospasme
(
) sputum
(
) darah
(
) lendir
(
) bebas / tanpa
(
) gurgling
(
)stridor
sumbatan Suara Nafas : (
) snoring
Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
2) Breathing ( Pernafsan ) Sesak, dengan (
) aktivitas
(
) tanpa aktivitas
(
) menggunakan otot
tambahan Frekuensi
:……………..x/menit
Irama
:(
) teratur
(
) tidak teratur
Kedalaman
:(
) dalam
(
) dangkal
Batuk
:(
) produktif
(
) non produktif
Sputum
:(
) ada
(
) tidak ada
Warna
: …………………………………………………………
Konsistensi
: …………………………………………………………
Bunyi Nafas
:
(
) ronchi
(
(
)……………………….
) wheezing
(
) crakels
Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
3) Circulation ( Sirkulasi ) Sirkulasi perifer : Nadi
: ………x/menit
Irama
:(
) teratur
(
) tidak teratur
Denyut
:(
) kuat
(
) lemah
TD
:…………mmHg
Ekstermitas
:(
(
) dingin
) hangat
Warna Kulit
:(
) sianosis
(
) pucat
(
) kemerahan
Nyeri dada
:(
) ada
(
) tidak ada
) menyebar
(
) seperti ditusuk-tusuk
Karakteristik nyeri dada : (
) menetap
(
(
) seperti ditimpa benda berat
CRT
:(
) < 2 detijk
(
) > 2 detik
Edema
:(
) iya
(
) tidak
(
) tungkai
Lokasi Edema : (
) muka
(
) tangan atas
(
)
) banyak
(
)
(
) putih
anasarka Eliminasi dan cairan : BAK
: ………………………x/menit
Jumlah
:(
) sedikit
Warna
:(
) kuning jernih (
) kuning kental
Rasa Sakit
:(
) iya
) tidak
BAB
: ………………………x/hari
(
sedang
(
Diare : (
) iya
(
) berlendir
(
) tidak
(
) berdarah
(
) cair
(
) buruk
Turgor
:(
) baik
(
) sedang
Mukosa
:(
) lembab
(
) kering
Suhu
: …………0C
Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
4) Disability Tingkat Kesadaran : (
) composmentis
(
) apatis
(
) somnolen
(
) stupor
(
) soporocoma
(
) koma
Pupil : (
) isokor
(
) midrasis
(
) anisokor
(
) negative
(
) negative
(
) miosis
Reaksi terhadap cahaya : Kanan ; (
) positif
Kiri (
:
) positif
GCS
:
Eve
Verbal
Motorik
Terjadi : (
) kejang
(
) pelo
(
)
(
) afasia
(
) disatria
kelumpuhan/kelemahan (
) mulut mencong
(
) berlendir
Nilai Kekuatan otot :
Refleks: Babinsky
: …………………………………………………………
Patella
: …………………………………………………………
Bisep/trisep
: …………………………………………………………
Brudynskt
: …………………………………………………………
Masalah Keperawatan
:
………………………………………………………………………………… …………………...……………………………….…………………………… ……………..…………………….…………………………………………… ……………….…..…………………….……………………………………… 5) Eksposure ………………………………………………………………………………… …………………...……………………………….…………………………… ……………..…………………….…………………………………………… ……………….…..…………………….………………………………………
Masalah Keperawatan : ………………………………………………………………………………… …………………...……………………………….…………………………… ……………..…………………….…………………………………………… ……………….…..…………………….………………………………………
D. PENGKAJIAN SEKUNDER 1) Keluhan Utama
: ………………………………………………………
Nyeri (bila ada nyeri) : P
: ………………………………………………………………………
Q
: ………………………………………………………………………
R
: ………………………………………………………………………
S
: ………………………………………………………………………
T
: ………………………………………………………………………
2) Alergi terhadap obat, makanan tertentu
: ………………………………
………………………………………………………………………………… ………………………………………………………………………………… 3) Medikasi/ pengobatan terakhir
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………….. 4) Event/ injury/ penyebab injury
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 5) Pengalaman atau pembedahan
:
………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
6) Riwayat penyakit sekarang
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 7) Riwayat penyakit Dahulu
:
………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 8) Pemeriksaan Fisik a. Kepala ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………
b. Leher ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… c. Dada ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… d. Abdomen ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………
e. Ekstermitas Luka
: (
) iya
(
) tidak
Dalam
: (
) iya
(
) tidak
Perdarahan
: (
) iya
(
) tidak
Deformitas
: ........................................................................................
Kontraktur
: ........................................................................................
Nyeri
: ........................................................................................
Krepitasi
: ........................................................................................
f. Kulit / integument Mukosa
:(
) lembab
(
) kering
Kulit
:(
) bintik merah
(
) jejas
(
) luka
(
) lecet
E. PEMERIKSAAN PENUNJANG Hari/Tanggal
Jenis Pemeriksaan
Hasil
Nilai Normal
F. ANALISA DATA NO
DATA
ETIOLOGI
PROBLEM
II.
DIAGNOSA KEPERAWATAN 1. …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... 2. …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... 3. …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... …………………………………………………………………………………….... ……………………………………………………………………………………....
III.
PERENCANAAN Diagnosa Keperawatan : …………………………………………………………………………………….........……………………………………………………… …………………………………………………………………………………….........……………………………………………………… …………………………………………………………………………………….........……………………………………………………… No
Tujuan dan Kriteria Hasil
Intervensi
Rasional
IV.
IMPLEMENTASI DAN EVALUASI No
Diagnosa Keperawatan
Jam
Implementasi
Paraf
Evaluasi
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