YAYASAN RUSTIDA

AKADEMI KESEHATAN RUSTIDA Program

Studi DIII Keperawatan Alamat : Jalan RSU.
Bhakti Husada Telp. (0333)821495, Fax:
(0333)821193 KRIKILAN – GLENMORE –
BANYUWANGI
FORMAT PENGKAJIAN ASUHAN KEPERAWATAN
GAWAT DARURAT (GADAR)

Nama Mahasiswa : ……………..................... Semester/Tingkat :...........................................

NIM : ………………………… Tempat Praktek :..........................................

Ruangan : ……………………………… No. Reg : ………………………………….

Tgl Pengkajian : ……………………………… Jam : ………………………………….

DATA KLIEN

A. DATA UMUM
1. Nama inisial klien : .........................................................
2. Umur : .........................................................
3. Alamat : .........................................................
4. Agama : .........................................................
5. Tanggal masuk RS : .........................................................
6. Nomor Rekam Medis : .........................................................

B. PENGKAJIAN PRIMER:

1. Airway/jalan nafas (paten/tidak jika tidak, penyebabnya, dan suara nafas)
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2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, frekuensi dan irama, jenis pernafasan, bantuan
nafas, dll)
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b. Palpasi (focal fremitus, dll)
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c. Perkusi (pembesaran paru, dll)
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d. Auskultasi (suara nafas)
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3. Circulation
a. Vital sign:
1) Tekanan darah : ....................................... mmHg
2) Nadi : ....................................... x/menit
3) Suhu : ........................................ oC
b. Capilarry refill : ........................................ detik
c. Sianosis/pucat : ………………………………………………………………………….
d. Akral : ………………………………………………………………………….
e. Kelembapan : ………………………………………………………………………….
f. Turgor : ………………………………………………………………………….
Lain-lain : ………………………………………………………………………….

4. Disability
a. GCS/AVPU : ………………………………………………………………………….
b. Pupil(diameter,isokor/anisokor, respon cahaya)
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c. Gangguan motorik :
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d. Gangguan sensorik :
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5. Expousere/Environment/Event
a. Adanya trauma pada daerah :
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b. Adanya jejas/luka pada daerah :
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c. Ukuran luka/jenis luka :
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d. Kedalaman luka :
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e. Lain2 (Px. Penunjang/proses kejadian) :
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C. SECONDERy SURVEY
6. Five Intervensi/Full Of Vital Sign
a. Five Intervensi
1) EKG :
2) Cateter :
3) NGT :
4) Sp O2 :
5) Laboratorium :

b. Full Of Vital Sign

1) TD/MAP :
2) Nadi :
3) Suhu :
4) Rr :
5) BB :

7. Give Comfort/beri kenyamanan

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8. History dan Head to toe
a. History
1) Keluhan utama :
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2) Riwayat pengakit sekarang :
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3) Makan-minum terakhir :

4) Riwayat medikasi :
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5) Pengalaman pembedahan :
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6) Alergi terhadap obat :
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7) Riwayat penyakit dahulu :
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8) Riwayat penyakit keluarga :
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b. Head to Toe
1) Kepala
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2) Leher
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3) Dada
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4) Abdomen
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5) Ekstremitas
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6) Kulit/integument
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D. TERAPI MEDIS

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