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Format Pengkajian Ugdidelain

Format Pengkajian Ugdidelain

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Published by ukim_sukiman1523

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Published by: ukim_sukiman1523 on May 22, 2010
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11/06/2012

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LOGO
RSUD AL IHSANPROVINSI JAWA BARAT
REKAMAN DATA PENGKAJIAN IGD
IDENTITAS
Nama lengkap :………………………………………Umur :………………thn/bln/hariNo Reg :……………………………… Triase :……………………………… Tgl :…./…../20.. Jam :………
PENGKAJIAN
Keluhan utama……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..……………...
Data Biologis
DataMasalah Keperawatan
A.AIR WAY 
Bersih 
Sumbatan : darah/sputum/caiean asing (pada mulut & hidung) 
Mulut terkatub trismus/bismus
Batuk produktif/tidak produktif 
 
…………………………………………………………………………………………..
B.BREATHING 
Pergerakan dada: simetris/asimetris 
Pola nafas : dyspnoe/tachipnoe/hiperpnoe/orthopnoe 
Suara nafas wheezing/ronchi/stridor/cracles : (…./…..) 
Sesak : saat istirahat/beraktivitas
 
Penggunaan otot nafas tambahan :
 
PCH/Retraksi/suprasternal
 
Suara perkusi
 
paru : (redup/sonor)
 
………………………………………………………………………………………………………………………………
C.CIRCULATION
 
Akral hangant/dingin 
Nadi : regular/irregular/kuat/lemah/tidak terabaCRT : > 3
detik/< 3 detik
Warna kulit : cyanosis/kemerahan
 
 Turgor : cepat/lambat kembali 
Kulit/membrane mukosa : kering/lembab 
Peningkatan JVP
 
Edema : wajah/anasarka/ekstemitas atas/bawah 
Perdarahan : …………..cc
 ……………………………………………………………………………………………………………………….……D.DISABILITY 
Kesadaran: CM/somnolent/spoor/ 
Reflek cahaya : ………../………… 
GCS : ……….. (E: ……M: ……V: …...) 
Kejang
AFGAR Score : 1’ :.... 5 ‘...... 
Hemiparese/plegia: (ekstremitas kiri/ka), tetraplegi 
Nyeri skala 1.2.3.4.5.6.7.8.9.10 
Luka :……………………………………………………………………………………………………………….…..
E.
ELIMINASI & OBSTETRI GINEKOLOGIALVI :
 
Perubahan pola BAB
Distensi abdomen
Perkusi abd dullness
Bersihan jalannafas tidakefektif 
Pola nafas tidakefektif 
Gangguanpertukaran gas
Kegagalanventilasi spontan
…………………………………………..
Kekuranganvolume cairan
Volume cairanberlebih
Penurunancardiac output
…………………………………………..
Nyeri akut/kronis
Perfusi jaringantidak efektif (otak)
Kerusakanintegritaskulit/jaringan
……………………

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