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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 ( ( ) darah ( sumbatan Suara Nafas : ( ) snoring
(
) bronkospasme ) lendir
( (
) sputum ) bebas / tanpa
) gurgling
(
)stridor
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 Denyut : ( ) kuat TD :…………mmHg Ekstermitas : ( ) hangat Warna Kulit : ( ) sianosis Nyeri dada : ( ) ada Karakteristik nyeri dada : ( ) menetap ( ) menyebar ( ) seperti ditimpa benda berat CRT : ( ) < 2 detijk Edema : ( ) iya Lokasi Edema : ( ) muka ( ) tangan atas
( (
) tidak teratur ) lemah
( ( (
) dingin ) pucat ( ) tidak ada
(
) seperti ditusuk-tusuk
( (
) > 2 detik ) tidak
(
) tungkai
(
)
anasarka Eliminasi dan cairan : BAK : ………………………x/menit Jumlah : ( ) sedikit ( ) banyak
(
)
: ( ) kuning jernih ( ) kuning kental : ( ) iya ( ) tidak : ………………………x/hari
(
) putih
(
sedang Warna Rasa Sakit BAB Diare : ( ) iya ( ) berlendir Turgor Mukosa
:( :(
) tidak ) baik ) lembab
) kemerahan
(
) berdarah
(
) cair
( (
) sedang ) kering
(
) buruk
Suhu : …………0C Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 4) Disability Tingkat Kesadaran : ( ) composmentis ( ) stupor Pupil : ( ) isokor ( ) midrasis Reaksi terhadap cahaya : Kanan ; ( ) positif Kiri : ( ) positif GCS : Eve Terjadi : ( ) kejang kelumpuhan/kelemahan ( ) mulut mencong ( ) berlendir Nilai Kekuatan otot :
( (
) apatis ) soporocoma
( (
) somnolen ) koma
(
) anisokor
(
) miosis
(
) negative
( ) negative Verbal Motorik (
) pelo
(
)
(
) afasia
(
) disatria
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 Dalam Perdarahan Deformitas
: ( : (
) iya ( ) tidak ) iya ( ) tidak : ( ) iya ( ) tidak : ............................................................................
............ Kontraktur : ........................................................................................ Nyeri : ........................................................................................ Krepitasi : ........................................................................................ f. Kulit / integument Mukosa : ( ) lembab ( ) kering
Kulit
: ( ) bintik merah ( ) luka
(
) jejas
(
) 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 ( ( ) darah ( sumbatan Suara Nafas : ( ) snoring
(
) bronkospasme ) lendir
( (
) sputum ) bebas / tanpa
) gurgling
(
)stridor
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 Denyut : ( ) kuat TD :…………mmHg Ekstermitas : ( ) hangat Warna Kulit : ( ) sianosis Nyeri dada : ( ) ada Karakteristik nyeri dada : ( ) menetap ( ) menyebar ( ) seperti ditimpa benda berat CRT : ( ) < 2 detijk Edema : ( ) iya Lokasi Edema : ( ) muka ( ) tangan atas
( (
) tidak teratur ) lemah
( ( (
) dingin ) pucat ( ) tidak ada
(
) seperti ditusuk-tusuk
( (
) > 2 detik ) tidak
(
) tungkai
(
)
anasarka Eliminasi dan cairan : BAK : ………………………x/menit Jumlah : ( ) sedikit ( ) banyak
(
)
: ( ) kuning jernih ( ) kuning kental : ( ) iya ( ) tidak : ………………………x/hari
(
) putih
(
sedang Warna Rasa Sakit BAB Diare : ( ) iya ( ) berlendir Turgor Mukosa
:( :(
) tidak ) baik ) lembab
) kemerahan
(
) berdarah
(
) cair
( (
) sedang ) kering
(
) buruk
Suhu : …………0C Masalah Keperawatan : ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… 4) Disability Tingkat Kesadaran : ( ) composmentis ( ) stupor Pupil : ( ) isokor ( ) midrasis Reaksi terhadap cahaya : Kanan ; ( ) positif Kiri : ( ) positif GCS : Eve Terjadi : ( ) kejang kelumpuhan/kelemahan ( ) mulut mencong ( ) berlendir Nilai Kekuatan otot :
( (
) apatis ) soporocoma
( (
) somnolen ) koma
(
) anisokor
(
) miosis
(
) negative
( ) negative Verbal Motorik (
) pelo
(
)
(
) afasia
(
) disatria
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 Dalam Perdarahan Deformitas
: ( : (
) iya ( ) tidak ) iya ( ) tidak : ( ) iya ( ) tidak : ............................................................................
............ Kontraktur : ........................................................................................ Nyeri : ........................................................................................ Krepitasi : ........................................................................................ f. Kulit / integument Mukosa : ( ) lembab ( ) kering
Kulit
: ( ) bintik merah ( ) luka
(
) jejas
(
) 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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