DEPARTEMEN GAWAT DARURAT

STIKES HANG TUAH SURABAYA

FORMAT PENGKAJIAN
KEPERAWATAN KEGAWATDARURATAN

Nama : No Rekam medik :

Jenis Kelamin : Pria  Wanita Tanggal lahir : ......./......./......... Umur: ............Tahun

A. PRE HOSPITAL
Waktu kedatangan : Transportasi : Kondisi datang :

Tindakan Pre Hospital :

CPR O2 Infus Bidai Bebat Urin Kateter
Lain – lain : ...............................................................................................................................................

B. INTRA HOSPITAL

TRIAGE
Tanggal : ................................... Jam :........................................... Perawat Triage........................
Allert Verbal Kategori Triage : Klasifikasi Kasus
Pain Unrespon P1 P2 P3 Trauma : Non Trauma

Keluhan Utama
Tanda dan gejala : ............................................................. Karakteristik:.............................................
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Onset : ............................................................................... ...................................................................
............................................................................................ Faktor yg meringankan :............................
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Lokasi ; .............................................................................. ...................................................................
............................................................................................ Tindakan yang telah dilakukan: ................
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Durasi : .............................................................................. ...................................................................
............................................................................................ Faktor Penyebab:......................................
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Riwayat Penyakit Dahulu : Diabetes melitus  Penyakit Jantung
Hipertensi CVA Asma
Lain- lain :...........................................................................................................................................
Allergi : Ada tidak. Jelaskan.....................................................................................................
GCS : E............ V........... M.......... Total :.......... Tensi : ........./........ mmHg HR : ......x/ menit
RR : ........ x/menit Suhu :  aksila .........ᴼC  Rektal ............ᴼC
AIRWAY CIRCULATION
Paten Obstruksi reguler ireguler
Irama jantung :
Akral : HKM dingin basah
Tindakan ........................................................
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......................................................................... Kulit : Sianosis Jaundice Pucat Normal
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BREATHING
CRT : < 2 Dtk > 2Dtk
Pergerakan dada :simetris asimetri, Turgor kulit : Baik sedang jelek
Irama pernapasan : Reguler Ireguler
Suara napas tambahan : Edema : tidak ada ada Lokasi :

Tidak ada ronchi  Crackles Perdarahan : tidak ada ada

rales stridor  wheezing Jenis ;...........................................................................

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DISABILITY PEMERIKSAAN HEAD TO TOE
Fraktur :  tidak ada  ada
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Lokasi : .......................................................... ......................................................................................
Tipe :....................................... ........................ ......................................................................................
Paralisis :  tidak ada  ada ......................................................................................
Lokasi : ................................... ....................... ......................................................................................
Diagram Tubuh : ......................................................................................
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PEMERIKSAAN DIAGNOSTIK
Jenis Pemeriksaan Hasil :
Darah Lengkap Kimia Klinik ............................................................................
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Gula darah Acak ............................................................................
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Blood Gas Analisa Kultur Urin EKG ............................................................................
BUN Kreatinin Foto Thorak ............................................................................
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Lain – lain ............................................................................
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Tindak lanjut : KRS MRS PP DOA OPERASI PINDAH LAIN LAIN

Pemberian Terapi
Jam Tindakan/ medikasi Keterangan

Waktu Analisa Data
Masalah Kep :
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DATA : (S& O)
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Masalah Kep :
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DATA : (S& O)
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ASUHAN KEPERAWATAN
Kriteria Hasil
Tujuan :
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Kriteria Hasil :
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Tujuan :
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Kriteria Hasil :
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Tindakan Evaluasi
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............................................................................ SOAPIE
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