ASUHAN KEPERAWATAN GAWAT DARURAT

ICU/ICCU
Nama Mahasiswa :__________________________
NIM :__________________________
Ruangan :__________________________

Tanggal masuk : Jam masuk :

Ruang : No. rekam medis :
Pengkajian :

I. IDENTITAS KLIEN
Nama : ______________
Umur : ______________ Penanggung jawab
Jenis kelamin : ______________ Nama :_______________
Pendidikan : ______________ Usia :_______________
Pekerjaan : ______________ Alamat : _______________
Alamat : ______________ Pendidikan : _______________
No RM : _______________ Pekerjaan : _______________
Dx. Medis : _______________ Suku/bangsa : _______________
Suku/ bangsa :________________

II. PENGKAJIAN
A. WAWANCARA
1. Keluhan utama:
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Riwayat penyakit sekarang:

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Riwayat penyakit dahulu:
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Riwayat penyakit keluarga:

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Riwayat Pekerjaan:
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 Riwayat Geografi:
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Riwayat alergi:
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Kebiasaan sosial:
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Kebiasaan merokok:
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B. PEMERIKSAAN FISIK
Keadaan umum: ____________________________________________________
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Sistem tubuh:
1. Breath (pernafasan)
- Respiratory rate : ____________________________________________
- Sound breath : ____________________________________________
- Oksigenasi : ____________________________________________
- Saturasi oksigen : ____________________________________________
- Bentuk dada : _________________________________________
- Lain-lain : ____________________________________________
2. Blood (kardiovaskuler)
- Nadi : __________________________________________
- Bunyi jantung : ____________________________________________
- EKG : ____________________________________________
- TD : ____________________________________________
- JVP : ____________________________________________
- Lain-lain : ____________________________________________

3. Brain (persyarafan)
- Tingkat kesadaran : ____________________________________________
- GCS : ____________________________________________
- Bentuk Kepala : ____________________________________________
- Mata : ____________________________________________
- Lain-lain : ____________________________________________

4. Bladder (perkemihan)
- Kandung kemih : ____________________________________________
- Urin : ____________________________________________
- Alat bantu : ____________________________________________
- Lain-lain : ____________________________________________

5. Bowel (pencernaan)
- Mulut : ______________________________________________
- Bunyi usus : ______________________________________________
- BAB : _______________________________________________
- Alat bantu : _______________________________________________
- Acites : ______________________________________________
- Hepatomegali : ______________________________________________
- Lain-lain : _______________________________________________

6. Bone (muskuloskeletal)
- ROM : ______________________________________________
- Deformitas ekstremitas : ______________________________________
- Mobillisai : ______________________________________________
 - Turgor : ______________________________________________
- Akral : ______________________________________________

7. Sosial
- Kooperatif : ______________________________________________
- Kemampuan komunikasi : _____________________________________

8. Spiritual
- Perilaku spiritual : ____________________________________________

III. HASIL UJI DIAGNOSTIK

A. Rontgen thoraks
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B. EKG
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C. AGD
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D. Lain-lain
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 E. Pemeriksaan Laboratorium
No Parameter Hasil Satuan Nilai Normal
 IV. TERAPI OBAT
Nama Obat Sediaan Dosis Jalur Masuk Fungsi
 V. ANALISA DATA
DATA ETIOLOGI MASALAH

VI. PRIORITAS DIAGNOSA KEPERAWATAN

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 VII. RENCANA KEPERAWATAN
No.Dx Tujuan Intervensi Rasional
No.Dx Tujuan Intervensi Rasional
VIII. IMPLEMENTASI
Tgl/Jam No. Dx Implementasi Respon Paraf
Tgl/Jam No. Dx Implementasi Respon Paraf
IX. EVALUASI

Tgl/Jam No. Dx Evaluasi (SOAP) Paraf

Tgl/Jam No. Dx Evaluasi (SOAP) Paraf