FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT DI IGD

I. Pengkajian
Nama Pengkaji :
Tanggal Pengkajian :
Jam Pengkajian :
A. Biodata Pasien
Nama :
Jenis Kelamin :
Pendidikan :
Pekerjaan :
Usia :
Status Pernikahan :
No.RM :
Diagnosa Medis :
Alamat :

B. Biodata Penanggung Jawab

Nama :
Jenis Kelamin :
Pendidikan :
Pekerjaan :
Hubungan dgn px :
Alamat :

C. Pengkajian Primer
1. Airway
Sumbatan :
( ) benda asing
( ) darah
( ) bronkospasme
( ) sputum
( ) lendir
( ) bebas tanpa sumbatan
Suara napas
( ) snoring
( ) gurgling
( ) stridor
Masalah keperawatan :
2. Breathing
Sesak dengan
( ) aktifitas
( ) tanpa aktifitas
( ) menggunakan otot tambahan
Frekuensi :.................x/menit
Irama : ( ) teratur ( ) tidak teratur
Kedalaman : ( ) dalam ( ) dangkal
 Batuk : ( ) produktif ( )non produktif
Sputum : ( ) ada ( ) tidak ada
Warana : ...........................................
Konsistensi : ...........................................
Bunyi nafas
( ) ronchi
( ) wheezing
( ) crakles
( ) ..............
Masalah keperawatan :

3. Circulation
Sirkulasi perifer
Nadi : ...................x/menit
Irama : ( ) teratur ( ) tidak teratur
Denyut : ( ) lemah ( ) kuat
TD : ..................mmHg
Ekstremitas : ( ) hangat ( ) dingin
Warna kulit : ( ) sianosis ( ) pucat ( ) kemerahan
Nyeri dada : ( ) ada ( ) tidak ada
Karakteristik nyeri dada
( ) menetap
( ) menyebar
( ) seperti ditusuk-tusuk
( ) seperti ditimpa benda berat
CRT : ( ) < 2 detik ( ) > 2 detik
Edema : ( ) iya ( ) tidak
Lokasi edema
( ) muka
( ) tangan atas
( ) tungkai
( ) anasarka
Eliminasi dan cairan
BAK : .................................. x/hari
Jumlah : ( ) sedikit ( ) banyak ( ) sedang
Warna : ( ) kuning jernih ( ) kuning kental ( ) putih
Rasa sakit : ( ) iya ( ) tidak
BAB : ................................... x/hari
Diare
( ) iya
( ) tidak
( ) berdarah
( ) cair
( ) berlendir
Turgor : ( ) baik ( ) sedang ( ) buruk
Mukosa : ( ) lembab ( ) kering
 Suhu : ..............................oC
Masalah Keperawatan :

4. Dissability
Tingkat kesadaran
( ) composmetis
( ) apatis
( ) somnolen
( ) stupor
( ) soporocoma
( ) koma
Pupil
( ) isokor
( ) anisokor
( ) miosis
( ) midriasis
Reaksi terhadap cahaya
Kanan
( ) positif
( ) negatif
Kiri
( ) positif
( ) negatif
GCS : ......................
Terjadi
( ) kejang
( ) pelo
( ) kelumpuhan/kelemahan
( ) mulut mencong
( ) afasia
( ) disartria
( ) berlendir
Nilai kekuatan otot

Reflkes :
Babinsky :
Patella :
Bisep/trisep :
Brudynsky :
Masalah keperawatan :

5. Eksposure
Pemeriksaan seluruh bagian tubuh terhadap adanya jejas dan perdarah dengan
pencegahan hipotermi
 Masalah keperawatan :
D. Pengkajian Sekunder
1. Keluhan utama
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2. Alergi terhadap obat makanan tertentu
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3. Medikasi-pengobatan terakhir
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4. Penyebab injury
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5. Pengalaman pembedahan
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6. Riwayat penyakit sekarang
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7. Riwayat penyakit dahulu
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8. Pemeriksaan head to toe
a. Kepala
Kesimetrisan wajah
Rambut : warna, distribusi, tekstur, tengkorak, kulit kepala
Sensori
Mata : inspeksi bola mata, kelopak mata, konjungtiva, sklera, reaksi pupil
terhadap cahaya
Telinga : letak, bentuk, serumen, kemampuan mendengar : uji berbisik
Hidung : deviasi septumnasi, kepatenan jalan napas lewat hidung, dicharge
Mulut : bibir sumbing, mukosa mulut, tonsil, gigi, gusi, lidah, bau mulut
b. Leher
Deviasi/simetriks, cidera cervikal
Kelenjar tyroid, kelenjar limfe, trakea, JVP
c. Dada
I : kesimetrisan, penggunaan otot bantu napas, iktus cordis
P : taktil fremitus, ada/tidaknya massa, iktus cordis terabatidak
 P : adanya cairan di paru, suara perkusi di paru dan jantung
A : suara paru, jantung
d. Abdomen
I : datar, cembung, cekung, lembek, elastis, asites, kembung
A : bising usus
P : posisi hepar, limpa, ginjal, kandung kemih, nyeri tekan
P : suara abnormal
e. Ekstremitas
Luka : ( ) ya ( ) tidak
Dalam : ( ) ya ( ) tidak
Perdarahan : ( ) ya ( ) tidak
Deformitas : kontraktur : nyeri : krepitasi

f. Kulit/integumen
Mukosa : ( ) lembab ( ) kering
Kulit : ( ) bintik merah ( ) jejas ( ) lecet ( ) luka

E. Pemeriksaan Penunjang
1. Pemeriksaan radiologi
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2. Pemeriksaan darah-urin-feses
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3. Pemeriksaan EKG
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F. Terapi Medis
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Analisa Data
No Data Etiologi Masalah Keperawatan
 II. Diagnosa Keperawatan
Disusun sesuai prioritas dan urgensinya

III. Perencanaan
Dx Kep :
No Tujuan dan kriteria Intervensi Rasional
maslah
IV. Implementasi dan Evaluasi
No Dx Kep Jam Implementasi Paraf Evaluasi