SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

PENGKAJIAN KEPERAWATAN GAWAT DARURAT DI RUANG IGD

BREATHNG

AIRWAY

IDENTITAS

Tgl/ jam :
No. RM
: ..
Triage : P1/P2/P3
Diagnosis Medis: ..
Transportasi : ambulan/mobil pribadi/lain-lain:...........................................
Nama : ........................................................ Jenis Kelamin : .................................................
Umur : ........................................................ Alamat : ............................................................
Agama : ...................................................... Status Perkawinan : ..........................................
Pendidikan : ............................................... Sumber Informasi : ...........................................
Pekerjaan : .................................................. Hubungan : .......................................................
Suku / bangsa : ........................................... Keluhan Utama : ..............................................
Jalan nafas : Paten
Tidak Paten
Obstruksi
: Lidah
Benda Asing Tidak ada
Cairan
Oedema
Muntahan
Darah
Suara nafas :
Tidak ada
Stridor
Snoring
Gurgling

Keluhan lain : ............................................................................................................................

....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
....................................................................................................................................................
Nafas

Spontan Tidak Spontan

Gerakan dinding dada

Simetri Asimetris

Normal
Ada
s
Irama nafas
Dangkal

Cepat Tidak Teratur

Pola nafas

Cyene
Lai

Teratur Kusmaul
Jenis
Stoke
n

Dispne Stridor
Suara nafas

Wheezi
Ron
u
Cuping hidung
Tidak ada
ng
chi
Vesikul Tidak ada
Retraksi otot bantu nafas
er
Pernafasan
Perut

Ada
RR: .........x/mnt

Ada

Dada

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 1

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

CIRCUL

Keluhan lain : ............................................................................................................................

....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
....................................................................................................................................................

ATION

DISABILITY

Nadi

Teraba
Tidak Teraba N: .........x/mnt
...................mmHg
Tekanan Darah

Ya
Tidak

Pucat

Ya
Tidak

Sianosis

< 2 dtk
> 2 dtk
CRT

Hangat
Dingin
Akral

Ada
Tidak ada
Perdarahan

..................................
Lokasi

..........cc
Jumlah

Elastis
Lambat
Turgor

Ya
Tidak
Diaphoresis
Luka Bakar

Diare
Muntah
Riwayat kehilangan cairan berlebih
Keluhan lain : ............................................................................................................................
....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
....................................................................................................................................................
Kesadaran

Compos
Delir
So
Ap
Kom
mentis
ium
mnolen
atis
a
GCS

Eye

Verb
Mot
Pupil

Me
al
orik
Isokor
Refleks Cahaya
driasis

Unis
Pin
Ada
Refleks Fisiologis
okor
point
Patela
Refleks Patologis

Tida
(+/-)
k Ada

Babinzk
...................
y (+/-)
Kekuatan Otot
...................

Kernig
...................
(+/-)

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 2

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

Lain.......
..........

EXPOSURE

Keluhan lain : ............................................................................................................................

....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
....................................................................................................................................................

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 3

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

Deformitas
Contusio
Abrasi
Penetrasi
Laserasi
Edema
Luka Bakar

Jika
terdapat Luka/
vulnus, kaji:

Ya
Ya
Ya
Ya
Ya
Ya
Ya
Grade .............%
Luas Luka
Warna Dasar Luka
Kedalaman Luka

Tidak
Tidak
Tidak
Tidak
Tidak
Tidak
Tidak

Lokasi ...............................
Lokasi ...............................
Lokasi ...............................
Lokasi ...............................
Lokasi ...............................
Lokasi ...............................
Lokasi ...............................
Lokasi ...............................

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

FIVE IIINTERVENTION

Keluhan lain : ............................................................................................................................

....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
...................................................................................................................................................
.
Monitoring jantung : sinus bradikardi sinus takikardi
Saturasi oksigen
: ............... %
Kateter urine
: ada
tidak ada
Pemasangan NGT : Ada, warna cairan lambung : .................................
Tidak

Terapi Medis:
....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
...............................................................................................................................................
.....................................................................................................................................................

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 4

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

...................................................................................................................................................
.....................................................................................................................................................
...................................................................................................................................................
Keluhan lain : ............................................................................................................................
....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
....................................................................................................................................................

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 5

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

Pemeriksaan Laboratorium:
....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
...............................................................................................................................................
.....................................................................................................................................................
...................................................................................................................................................
.....................................................................................................................................................
...................................................................................................................................................
....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
...............................................................................................................................................
.....................................................................................................................................................
...................................................................................................................................................
.....................................................................................................................................................
...................................................................................................................................................
....................................................................................................................................................

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 6

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI

HISTORY

GIVE COMFORT

Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

Nyeri
: Ada
Tidak Ada
Problem
: .......................................................................................................................
....................................................................................................................................................
Qualitas/ quantitas : ...................................................................................................................
....................................................................................................................................................
Regio : .......................................................................................................................................
....................................................................................................................................................
Skala : ........................................................................................................................................
....................................................................................................................................................
Timing : .....................................................................................................................................
....................................................................................................................................................
Keluhan lain : ............................................................................................................................
....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
....................................................................................................................................................
Keluhan utama :
....................................................................................................................................................
....................................................................................................................................................
Mekanisme cidera (trauma) :
.....................................................................................................................................................
...................................................................................................................................................
....................................................................................................................................................
Sign / tanda gejala :
.....................................................................................................................................................

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 7

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI

HEAD TO TOE

HEAD TO TOE

Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

.....................................................................................................................................................
..................................................................................................................................................
Alergi :
....................................................................................................................................................
Medication / pengobatan :
.....................................................................................................................................................
...................................................................................................................................................
Post Medical History :
.....................................................................................................................................................
...................................................................................................................................................
Last Oral Intake:
....................................................................................................................................................
....................................................................................................................................................
Event Leading Injury:
.....................................................................................................................................................
...................................................................................................................................................
(fokus pemeriksaan pada daerah trauma / sesuai kasus nontrauma )
Kepala dan wajah
Inspeksi :
.....................................................................................................................................................
...................................................................................................................................................
Palpasi :
....................................................................................................................................................
....................................................................................................................................................
Leher
Inspeksi :
.....................................................................................................................................................
...................................................................................................................................................
Palpasi :
....................................................................................................................................................
....................................................................................................................................................
Dada
Inspeksi :
.....................................................................................................................................................

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 8

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

...................................................................................................................................................
Palpasi :
....................................................................................................................................................
....................................................................................................................................................
Perkusi :
.....................................................................................................................................................
...................................................................................................................................................
Auskultasi :
....................................................................................................................................................
....................................................................................................................................................
Abdomen
Inspeksi :
.....................................................................................................................................................
...................................................................................................................................................
Auskultasi :
....................................................................................................................................................
....................................................................................................................................................
Palpasi :
.....................................................................................................................................................
...................................................................................................................................................
Perkusi :
....................................................................................................................................................
....................................................................................................................................................
Pelvis dan perineum :
.....................................................................................................................................................
...................................................................................................................................................
Ekstremitas :
Atas:
.....................................................................................................................................................
.....................................................................................................................................................
..................................................................................................................................................
Bawah
..................................................................................................................................................
..................................................................................................................................................
Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari
Tahun 2015 | 9

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI

INSPECTION BACK/ POSTERIOR SURFACE

Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

..................................................................................................................................................
Masalah keperawatan :
.....................................................................................................................................................
...................................................................................................................................................
Jejas
: Ada
Tidak
....................................................................................................................................................
Deformitas
: Ada
Tidak
....................................................................................................................................................
Tenderness
: Ada
Tidak
....................................................................................................................................................
Crepitasi
: Ada
Tidak
....................................................................................................................................................
Laserasi
: Ada
Tidak
....................................................................................................................................................
Keluhan lain : ............................................................................................................................
....................................................................................................................................................
Masalah keperawatan : ...............................................................................................................
....................................................................................................................................................

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 10

SEKOLAH TINGGI ILMU KESEHATAN (STIK)

AVICENNA KENDARI
Jl. Y. Wayong By Pass Lepo-Lepo Kendari. Telp/fax (.0401)392294, e-mail : stika_kendari@yahoo.com

Keperawatan Gawat Darurat (GADAR I) Profesi Ners STIK Avicenna Kendari

Tahun 2015 | 11