Format Pengkajian Gadar New 2012
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FORMAT PENGKAJIAN KEPERAWATANGAWAT DARURAT
Pengkajian tgl. : Jam :MRS tanggal : No. RM :Diagnosa Masuk : Hari Rawat Ke :Ruangan/kelas :
A. IDENTITAS PASIENNama : Penanggung jawab biaya :Usia : Nama :Jenis kelamin : Alamat :Suku /Bangsa : Hub. Keluarga :Agama : Telepon :Pendidikan :Status perkawinan Pekerjaan :Alamat :
B. RIWAYAT PENYAKIT SEKARANG1. Keluhan Utama : .......................................................................................................................2. PENGKAJIAN PRIMER
A. Airway :
B. Breathing :
C. Circulation :
D. Disability :
E. Eksposure :
C. RIWAYAT PENYAKIT DAHULU1. Pernah di rawat ya, jenis : ....................... tidak2. Riwayat Penyakit Kronik dan Menular ya, jenis : ....................... tidak3. Riwayat Penyakit Alergi ya, jenis : ....................... tidak4. Riwayat Operasi ya, jenis : ....................... tidak
- Kapan : ...............................- Jenis Operasi : ...............................
5. Lain-lain :...................................................................................................................................................................................................................................................................................................................................................................................................................................................
PROGRAM STUDI S1 KEPERAWATANSEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN
KampusA : Jl. P. Diponegoro 17 Tuban (62315) | Telp. (0356) 321287 | Fax. (0356) 333237 | KampusB : Jl. LetdaSucipto 211 Tuban (62351) | Telp. (0356) 325789 | (0356) 712572 | Website.http://www.stikesnu.com | Email. [email protected]
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D. RIWAYAT PENYAKIT KELUARGAya : ........................................ tidak
GENOGRAM
E. PERILAKU YANG MEMPENGARUHI KESEHATANPerilaku sebelum sakit yang mempengaruhi kesehatan
Alkohol ya tidakKeterangan ..........................................................................................................Merokok ya tidakKeterangan ..........................................................................................................Obat ya tidakKeterangan ..........................................................................................................Olahraga ya tidakKeterangan ..........................................................................................................
F. OBSERVASI DAN PEMERIKSAAN FISIK1. Keadaan Umum
Tanda-tanda vitalKeadaan umum baik sedang lemahS : ºC N : x/mnt TD : mmHgRR : x/mnt
MASALAH KEPERAWATAN :..................................................................................................................................................................................................................................................................................................
2. Sistem Pernafasana. RR : ...............................b. Keluhan : Sesak Nyeri waktu sesak Orthopnea
Batuk Produktif Tidak ProduktifSekret : .................... Konsistensi : .......................Warna : ................... Bau : ....................................
c. Pola nafas irama: Teratur Tidak teratur
d. Jenis Dispnoe Kusmaul Ceyne Stokes Lain-lain:
Pernafasan cuping hidung ada tidakSeptum nasi simetris tidak simetrisLain-lain :
e. Bentuk dada simetris asimetris barrel chestFunnel chest Pigeons chest
f. Suara napas vesiculer ronchi D/S wheezing D/S rales D/Sg. Alat bantu nafas Ya Tidak
Jenis .........................Flow ................Lpmh. Penggunaan WSD :
- Jenis : ....................................................................................................................- Jumlah Cairan :.........................................................................................................- Undulasi : .................................................................................................................- Tekanan : .................................................................................................................
i. Trakeostomy Ya Tidak................................................................................................................................................
j. Lain-lain :................................................................................................................................................
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MASALAH KEPERAWATAN :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Sistem Kardiovakulera. Keluhan nyeri dada ya tidak
P : .....................................................................................Q : .....................................................................................R : .....................................................................................S : .....................................................................................T : .....................................................................................
b. CRT : ...............c. Konjungtiva pucat ya tidakd. Bunyijantung: Normal Murmur Gallop lain-lain
e. Iramajantung: Reguler Ireguler S1/S2 tunggal Ya Tidak
f. Akral: Hangat Panas Dingin kering Dingin basah
g. Siklus perifer Normal Menurun
h. JVP : ..........................
Lain-lain : ..................................................................................................................................................................................................................................................................................................
MASALAH KEPERAWATAN :................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Sistem Persarafana. Kesadaran composmentis apatis somnolen sopor koma
GCS :b. Pupil isokor anisokorc. Sclera Anikterus Ikterusd. Konjungtiva Ananemis Anemise. Istirahat/Tidur : .................................................f. Nyeri tidak ya, skala nyeri : lokasi :g. Refleksfisiologis: patella triceps biceps lain-lain:
h. Reflekspatologis: babinskybudzinsky kernig lain-lain
i. Keluhan Pusing O ya O Tidak
MASALAH KEPERAWATAN :...............................................................................................................................................................................................................................................................................................................................................................................................................................................................
5. Sistem Perkemihan (B4)a. Kebersihan genetalia : Bersih Kotorb. Sekret : Ada Tidakc. Ulkus : Ada Tidak d. Kebersihan Meatus uretera : Bersih Kotore. Keluhan Kencing Ada Tidak
Bila ada jelaskan :........................................................................................................................................................................................................................................................................................................
f. Kemampuan berkemihSpontan Alat bantu, sebutkan : ...................................................................
Jenis : ........................................................................................Ukuran : ........................................................................................
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Hari Ke: ........................................................................................g. Produksi urine : ...........................ml/jam
Warnah : ...............................Bau : ...............................
h. Kandung kemih : Membesar Ya Tidaki. Nyeri Tekan : Ya Tidakj. Intake Cairan: Oral :....................cc/hari Parenteral : ..............cc/harik. Balance Cairan : ..................................................................................................................
....................................................................................................................................................
....................................................................................................................................................o. Lain-lain : .....................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................MASALAH KEPERAWATAN : ............................................................................................................................................................................................................................................................................................................................................................................................................................................................
6. Sistem Pencernaana. TB : ............. cm BB : ..............kgb. IMT : ............. Interpretasi : .........................................c. LLA : .............MASALAH KEPERAWATAN :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................d. Mulut : Bersih Kotore. Mukosa mulut : Lembab Kering Merah stomatitisf. Tenggorokan Nyeri telan Sulit menelan
Pembesaran Tonsil Nyeri Tekang. Abdomen Supel Tegang nyeri tekan, lokasi :
Luka operasi Jejas lokasi :Pembesaran hepar ya tidakPembesaran lien ya tidakAscites ya tidakDrain Ada Tidak- Jumlah : ......................- Warna : ......................- Kondisi area sekitar insersi : .....................................Mual ya tidakMuntah ya tidakTerpasang NGT ya tidakBising usus :..........x/mnt
h. BAB :........x/hr, konsistensi : lunak cair lendir/darah
konstipasi inkontinensia kolostomii. Diet padat lunak cair
Diet Khusus : ......................................................................................................................Nafsu Makan Baik Menurun Frekuensi :...............x/hari jumlah:............... jenis : .......................Lain –lain : ..........................................................................................................................
MASALAH KEPERAWATAN :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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7. Sistem Penglihatana. Pengkajian segmen anterior dan posterior
Orbita Dextra Orbita SinistraVisus
PalpebraConjunctiva
KorneaBMDPupilIris
LensaTIO
b. Keluhan nyeri Ya Tidakc. Luka opreasi Ada Tidak
Tanggal operasi : ........................Jenis Operasi : ........................Lokasi : ........................Keadaan : ........................
d. Pemeriksaan penunjang lain..........................................................................................................................................................
e. Lain ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................
MASALAH KEPERAWATAN ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Sistem pendengarana. Pengkajian segmen dan posteriorb. Aurcicula :c. MAE :d. Membran Tympani :e. Rinne :f. Webber :g. Swabach :h. Tes audiometri :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................i. Keluhan nyeri Ya Tidak
j. Luka opreasi Ada TidakTanggal operasi : ........................Jenis Operasi : ........................Lokasi : ........................Keadaan : ........................
k. Alat bantu dengar : .......................................................l. Lain-lain. ......................................................................................................................................
.......................................................................................................................................................MASALAH KEPERAWATAN.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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9. Sistem Muskuloskeletal dan Integumen (B6)a. Kekuatan otot
b. Pergerakan sendi bebas terbatasc. Kelainan ekstremitas ya tidakd. Kelainan tlg. belakang ya tidake. Fraktur ya tidak
- Jenis :..............................................................f. Traksi/spalk/gips ya tidak
- Jenis : ............................................- Beban : ............................................- Lama pemasangan : ...........................................
g. Penggunaan spalk/gips ya tidakh. Keluhan nyeri : ya tidaki. Sirkulasi perifer : ...........................................j. Kompartemen sindrom ya tidakk. Kulit ikterik sianosis kemerahan hiperpigmentasil. Akral hangat panas dingin kering basahm. Turgor baik kurang jelekn. Odema: Ada Tidakada Lokasi
o. Luka operasi : jenis :............. luas : ............... bersih kotorp. Tanggal operasi : ..................q. Jenis operasi : ..................r. Lokasi : ..................s. Keadaan : ..................t. Drain : Ada Tidaku. Jumlah : ...................................................v. Warna : ...................................................
Lain-lain : ................................................................................................................................................................................................................................................................
MASALAH KEPERAWATAN :..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10. Sistem Integumena. Penilaian risiko decubitus :
Aspek yang dinilai KRITERIA YANG DINILAI NILAI1 3 3 4
PERSEPSI SENSORI
TERBATAS SEPENUHNYA
SANGAT TERBATAS
KETERBATASAN RINGAN
TIDAK ADA GANGGUAN
KELEMBABAN TERUS MENERUS BASAH
SANGAT LEMBAB KADANG-KADANG BASAH
JARANG BASAH
AKTIVITAS BEDFAST CHAIRFAST KADANG-KADANG JALAN
LEBIH SERING JALAN
MOBILISASI IMMOBILE SEPENUHNYA
SANGAT TERBATAS
KETERBATASAN RINGAN
TIDAK ADA KETERBATASAN
NUTRISI SANGAT BURUK KEMUNGKINAN TIDAK ADEKUAT
ADEKUAT SANGAT BAIK
GESEKAN & PERGESERAN
BERMASALAH POTENSIAL BERMASALAH
TIDAK MENIMBULKAN
MASALAH
NOTE : Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko mengalami dekubitus (Pressure ulcers)(15 or 16 =low risk, 13 or 14 = moderate risk, 12 or less= high risk)
TOTAL NILAI
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b. Warna : ...........................................................c. Pitting edema : +/- grade : ..............................d. Ekskoriasis : ya tidake. Psoriasis : ya tidakf. Urtikaria : ya tidakg. Lain-lain : ............................................................................................................................
..............................................................................................................................................MASALAH KEPERAWATAN ..........................................................................................................................................................................................................................................................................................................................................................................................................................................
11. Sistem Endokrin a. Pembesaran kelenjar tyroid ya tidakb. Pembesaran kelenjar getah bening ya tidakc. HiperglikemiaYaTidakHipoglikemia Ya Tidak
d. Kondisi kaki DM :
- Luka gangrene Ya Tidak
- Jenis Luka : .....................................................
- Lama luka : .....................................................
- Warna : .....................................................
- Luas Luka : .....................................................
- Kedalaman : .....................................................
- Kulit Kaki : ..............................................- Kuku kaki : ..............................................- Telapak kaki : ..............................................- Jari kaki : ..............................................- Infeksi : Ya Tidak
- Riwayat luka sebelumnya : Ya Tidak
- Tahun : ..................................................
- Jenis Luka : ..................................................
- Lokasi : ..................................................
- Riwayat amputansi sebelumnya : Ya TidakJika Ya
- Tahun : ..........................
- Lokasi : .........................
- Lain-lain : ............................................................................................................................................................................................................................
MASALAH KEPERAWATAN :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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G. PENGKAJIAN PSIKOSOSIAL1. Persepsi klien terhadap penyakitnya
Cobaan Tuhan Hukuman Lainnya2. Ekspresi klien terhadap penyakitnya
Murung Gelisah Tegang Marah/menangis3. Reaksi saat interaksi kooperatif tak kooperatif curiga4. Gangguan konsep diri ya tidak
MASALAH KEPERAWATAN :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
H. PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah- Sebelum sakit sering kadang-kadang tidak pernah- Selama sakit sering kadang-kadang tidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
MASALAH KEPERAWATAN :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
I. PERSONAL HYGIENa. Kebersihan diri :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
b. Kemampuan klien dalam pemenuhan kebutuhan :- Mandi : Dibantu seluruhnya dibantu sebagian mandiri- Ganti pakaian : Dibantu seluruhnya dibantu sebagian mandiri- Keramas : Dibantu seluruhnya dibantu sebagian mandiri- Sikat gigi : Dibantu seluruhnya dibantu sebagian mandiri- Memotong kuku: Dibantu seluruhnya dibantu sebagian mandiri- Berhias : Dibantu seluruhnya dibantu sebagian mandiri- Makan : Dibantu seluruhnya dibantu sebagian mandiri
MASALAH KEPERAWATAN :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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J. PEMERIKSAAN PENUNJANG(Laboratorium, radiologi, EKG, USG)
K. TERAPI
Tuban,.................................Perawat Primer,
(.............................................)
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ANALISA DATA
DATA ETIOLOGI MASALAH
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DIAGNOSA KEPERAWATAN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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INTERVENSINo Diagnosa Keperawatan Tujuan/
Kriteria HasilTgl/jam Intervensi Rasional
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IMPLEMENTASI DAN EVALUASIDIAGNOSA IMPLEMENTASI JAM/TGL EVALUASI SOAP
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