ASUHAN KEPERAWATAN GAWAT DARURAT

Nama/Usia
Jenis kelamin
Alamat
Nomor register
MRS
Tanggal Pengkajian
Diagnosa medis
Keluhan
Keadaan Umum

: Tn. I/ 49 tahun
: Laki-laki
: Jl. Belitung Darat G.AA, Banjarmasin
: 1-14-24-XX
: 5 Maret 2015
: 5 Maret 2015
: STEMI + CHF
: Pasien mengeluhkan sesak dan batuk sejak 2 hari yang lalu nyeri pada bagain dada, demam sejak 4 hari yang
lalu, nyeri tekan pada bagian ulu hati nafsu makan menurun dan kepala terasa pusing.
: Pasien tampak sesak, pasien tampak meringis sambil memegangi daerah dadanya.

PRIMARY ASSESMENT
A. AIRWAY (JALAN NAFAS)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

B. BREATHING (NAFAS)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

DO:
- Pasien tampak sesak
- TD: 110/90 mmHg
- N: 116 x/mnt
- RR: 40 x/mnt
- T: 38,2C
- SPO2 : 95%
DS:
Pasien mengeluhkan
sesak nafas
Pasien mengeluhkan
nyeri dada

Pola nafas tidak efektif

b.d

C. CIRCULATION (SIRKULASI)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

D. DISABILITY : AVPU
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

E. EXPOSURE
TEMUAN

ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

SECONDARY ASSESMENT
1. Keadaan umum:

2. History:
a) S (Signs & Symptom): .

.
b) A (Allergies): ..
.
c) M (Medication): ..

d) P (Past Medical History):

.
e) L (Last Meal, Last Menstrual):

f)

E (Events): ..

3. Subjektif
Nyeri Dada: tidak terkaji
S : .
O : .
C : .
R : .
A : .
T : .
E : .
S : .
Nyeri Abdomen: tidak terkaji
P : .
Q : .

R : .
S : .
T : .

4. Objektif:
Observasi tanda-tanda vital dan SaO2
TTV :
BP
= mmHg
HR
= x/menit
RR
= x/menit
T
= 0C
SaO2
=

5. Pemeriksaan Head To Toe:

No.
1.

BAGIAN
Kepala

TEMUAN
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................

2.

Wajah

3.

Servikalis Dan
Leher

4.

Toraks

.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
. .................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................

5.

Abdomen

6.

Pelvis

7.

Ekstremitas

.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
................................................................................................................................................................................. .
................................................................................................................................................................................ ..
............................................................................................................................................................................... ...
.............................................................................................................................................................................. ....
............................................................................................................................................................................. .....
............................................................................................................................................................................ ......
........................................................................................................................................................................... .......
...................................................................................................................................................................................
...........................................................................................................................................................................

8.

Bagian
Punggung

9.

Neurologis

...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................

PEMERIKSAAN PENUNJANG
1. Laboratorium
Pemeriksaan
HEMATOLOGI
Hemoglobin
Lekosit
Eritrosit
Hematokrit
Trombosit
RDW-CV

Hasil
.
..
.
..
.
..
.

Nilai Rujukan

Satuan

Metoda

14,00 - 16,00
4,0 - 10,5
3,90 5,50
37,00 47,00
150 450
11,5 14,7

gr/dL
ribu/uL
juta/uL
vol %
ribu/uL
%

Colorimetric
Impedance
Impedance
Analyzer Calculates
Impedance
Analyzer Calculates

..
.
..
.
..
MCV, MCH, MCHC
MCV
MCH
MCHC

HITUNG JENIS
Gran %
Limfosit %
MID %
Gran #
Limfosit #
MID #

.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
..
.
.
.
...

80,0-97,0
27,0-32,0
32,0-38,0

fl
pg
%

Analyzer Calculates
Analyzer Calculates
Analyzer Calculates

50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0

%
%
%
ribu/ uL
ribu/ uL
ribu/ uL

Impedance
Impedance
Impedance
Impedance
Impedance
Impedance

KIMIA
Glukosa darah puasa
Hati
SGOT
SGPT
Alumin
Ginjal
Ureum
Kreatinin
Elektrolit
Natrium
Kalium
Clorida
Faal Lemak Dan
Jantung
LDH
CKMB

.
..
.
..
.
..
.
..
.
..
4.1
.
..
.
..
.
..
.
..
140.7
3.6
106.0
619
22

2.

Foto
Hasil foto thorax (rontgen) :

<200

mg/ dL

GOD-PAP

0-46
0-45
3.5-5.5
10-50
0.6-1.2

u /l
u/l
g/dl
mg/dl
mg/dl

135-146
3,4-5,4
95-100

mmol/l
mmol/l
mmol/l

IFFC
IFFC
Biuret
Modif-berhelot
Jaffe
ISE
ISE
ISE

225-450
0-24

mmol/l
mmol/l

ISE
ISE

...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
CTR= a + b x 100% =
C
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
Hasil CT Scan :
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................

...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
Kesimpulan:

3. EKG :

Interpretasi EKG :