STIKES NANI HASANUDDIN MAKASSAR

PROGRAM STUDI S1 KEPERAWATAN

FORMAT PENGKAJIAN KASUS TRAUMA

KEPERAWATAN GAWAT DARURAT
(DI INSTALASI RAWAT DARURAT)

I.

Tgl Masuk Rumah Sakit

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

Tgl Pengkajian

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

Nomor Register

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

Ruangan / Rumah Sakit

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

Diagnosa Medis

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

BIODATA
A. Identitas Pasien
1. Nama Lengkap
2. Jenis Kelamin
3. Umur / Tanggal Lahir
4. Kawin / Belum Kawin
5. A g a m a
6. Suku / Bangsa
7. Pendidikan
8. Pendapatan
9. Pekerjaan
10. Nomor Askes
11. Alamat

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B. Identitas Penanggung
1. Nama Lengkap
2. Jenis Kelamin
3. Umur / Tanggal Lahir
4. A g a m a
5. Suku / Bangsa
6. Pendidikan
7. Pendapatan
8. Pekerjaan
9. Hubungan dengan pasien
10. Alamat

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II.

RIWAYAT KESEHATAN
A. Riwayat Kesehatan Sekarang
1. Keluhan Utama
: ................................................................................
2. Riwayat keluhan utama
a. Provoking (pencetus)
: ...............................................................
......................................................................................................... ..................
b. Quality (kualitas)
: ...............................................................
...........................................................................................................................
c. Region (lokasi)
: ...............................................................
...........................................................................................................................
d. Severity (berat/ringan)/skala
: ...............................................................
............................................................................................................................
e. Time (waktu)
: ...............................................................
................................................................................................................................
3. Apakah keluhan bertambah / berkurang pada saat tertentu / memperberat atau
meringankan keluhan
: ...............................................................
4. Hal hal yang memperberat / meringankan keluhan : ....................................................
5. ABCDE
Airway :
- Apakah ada tanda-tanda sumbatan jalan nafas : ......................................................
- Apakah terdengar bunyi stridor : ..........................................................................
- Apakah ada tanda-tanda keberadaan benda asing, darah, muntah dalam mulut ....
Breathing
- Frekuensi napas
- Pengembangan dada
- Retraksi intercostal
- Bunyi napas
Circulation

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:

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(ngorok, bersiul, megap, dll)

- A
Disability
- S
6. AMPLE
a. Allergies (alergi)
: ....................................................................................................
b. Medication (obat-obatan) : ..................................................................................
...........................................................................................................................
c. Past history (riwayat singkat penyakit, kecelakaan, tindakan pembedahan, dan
perawatan selama sakit. : ........ .......... ............. ............ ............. ............. ......... .....
.................................................................................................. ........................
d. Last time ate or drank (waktu terakhir makan dan minum) : ........ .......... .............
...........................................................................................................................
e. Event (apa yang menyebabkan terjadinya kecelakaan? Kecelakaan kendaraan, luka
bakar, dll
: .....................................................................................................
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III.

PEMERIKSAAN FISIK
1. Keadaan umum
2. TTV
Tekanan darah

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

Nadi

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

Pernapasan

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

Suhu

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

3. Berat Badan
: ...........................................................................................................
4. Tinggi Badan
: ...........................................................................................................
5. Kepala
- Reaksi pupil terhadap cahaya, ukuran : ....................................................................
- Apakah ada luka? Deformitas/cacat?, memar, pembengkakan, tulang yang penyek ke
dalam : ...................................................................................................................
- Apakah ada cairan yang keluar dari telinga atau hidung ? : ................................
................................................................................................................................
- Periksa adanya nyeri tekan .......................................................................................
- Ukur Glasgow Coma Scale :
Eye (Mata)
: .......... (........................................................................................)
M (Motorik)

: .......... (........................................................................................)

V (Verbal)

: .......... (........................................................................................)

Jumlah skor

: .......... (..........................)

6. Leher
- Tanda-tanda injury spinal : ......................................................................................
- Apakah ada luka? Deformitas? Memar? Dan pembengkakan? : ...................................
- Apakah ada distensi/penggembungan dari vena leher? ..............................................
- Perhatikan posisi trakhea apakah ditengah-tengah atau terdorong ke salah satu sisi
............................................................................................................................. ...
- Rasakan apakah ada udara di bawah kulit (empisema subkutan).................................
7. Dada
- Hasil pemeriksaan EKG : .........................................................................................
- Kecepatan nafas : ...............x/menit, upaya nafas : ..................................................
- Pengembangan dada (simetris/tidak) : ......................................................................
- Apakah ada luka, deformitas, memar, bengkak, atau depresi tulang (tulang masuk ke
dalam) ........................................................................................................... .........
- Bunyi napas : ............................................ kiri/kanan : ..........................................
8. Perut
- Apakah ada luka, memar, bengkak pada kulit, atau pembesaran pada seluruh perut
(distensi) .................................................................................................................
- Apakah ada skar (bekas luka) yang lama : .................................................................
- Bising usus : ................................. pristaltik usus : .............x/menit
- Nyeri pada kuadran abdomen : ...................................................., kekakuan : ................
.............................., atau tampak sikap menjaga area perut yang mengindikasi
perdarahan pada perut.
9. Pelvis, Rektum dan Genital
- Apakah ada luka, deformitas, atau memar?................................................................
- Apakah ada perdarahan dari urethra?........................................................................
- Apakah ada perdarahan sekitar skrotum, rektum, atau vagina?...................................
............................................................................................................................. ...

- Apakah ada fraktur atau dislokasi?............................................................................

10. Lengan dan tungkai
- Apakah ada luka, deformitas, memar, atau pembengkakan?........................................
- Apakah ada nyeri tekan? Apakah pasien dapat merasakan sensasi sentuhan yang anda
lakukan? Pergerakan sendi?......................................................................................
- Nadi perifer ada/tidak?
- Suhu anggota gerak, tangan, dan kaki? Panas atau dingin?.......................................
11. Punggung
- Apakah ada luka, deformitas, memar, pembengkakan, depresi tulang?.........................
- Apakah ada perdarahan yang berasal dari anus?........................................................
- Apakah ada nyeri tekan?...........................................................................................
IV.

PEMERIKSAAN DIAGNOSTIK
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V.

DATA LAIN-LAIN YANG DIANGGAP PERLU

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VI.

PERAWATAN/PENGOBATAN
1. Perawatan
Tindakan perawatan yang diberikan .....................................................................................
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2. Pengobatan
Tindakan pengobatan yang diberikan.............................................................. ......................
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Catatan :
Jika ada hal-hal yang ada dipengkajian silahkan di tambah ..............................................................