PROGRAM STUDI S1 KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN

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FORMAT PENGKAJIAN KEPERAWATANGAWAT DARURAT

Pengkajian tgl.
MRS tanggal
Diagnosa Masuk
Ruangan/kelas

:
:
:
:

Jam
No. RM
Hari Rawat Ke

:
:
:

A. IDENTITAS PASIEN
Nama
:
Penanggung jawab biaya :
Usia
:
Nama
:
Jenis kelamin :
Alamat
:
Suku /Bangsa :
Hub. Keluarga
:
Agama
:
Telepon
:
Pendidikan :
Status perkawinan
Pekerjaan
:
Alamat
:
B. RIWAYAT PENYAKIT SEKARANG
1. Keluhan Utama : .......................................................................................................................
2. PENGKAJIAN PRIMER
A. Airway
:

B. Breathing :

C. Circulation

D. Disability :

E. Eksposure :

C. RIWAYAT PENYAKIT DAHULU

1. Pernah di rawat
ya, jenis : .......................
tidak
2. Riwayat Penyakit Kronik dan Menular
ya, jenis : .......................
tidak
3. Riwayat Penyakit Alergi
ya, jenis : .......................
tidak
4. Riwayat Operasi
ya, jenis : .......................
tidak
- Kapan
: ...............................
- Jenis Operasi
: ...............................
5.
Lain-lain :
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

D. RIWAYAT PENYAKIT KELUARGA

ya : ........................................

tidak

GENOGRAM

E. PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan
Alkohol
ya
tidak
Keterangan ..........................................................................................................
Merokok
ya
tidak
Keterangan ..........................................................................................................
Obat
ya
tidak
Keterangan ..........................................................................................................
Olahraga
ya
tidak
Keterangan ..........................................................................................................
F. OBSERVASI DAN PEMERIKSAAN FISIK
1. Keadaan Umum
Tanda-tanda vital
Keadaan umum
baik
sedang
lemah
S:
C
N:
x/mnt
TD :
RR : x/mnt

mmHg

MASALAH KEPERAWATAN :
.................................................................................................................................................
.................................................................................................................................................
2. Sistem Pernafasan
a. RR : ...............................
b. Keluhan :
Sesak
Nyeri waktu sesak
Orthopnea
Batuk
Produktif
Tidak Produktif
Sekret : ....................
Konsistensi : .......................
Warna : ...................
Bau : ....................................
c. Pola nafas
irama:
Teratur
Tidak teratur
d. Jenis
Dispnoe
Kusmaul Ceyne Stokes
Lain-lain:
Pernafasan cuping hidung
ada
tidak
Septum nasi
simetris
tidak simetris
Lain-lain :
e. Bentuk dada simetris
asimetris
barrel chest
Funnel chest
Pigeons chest
f. Suara napas vesiculer
ronchi D/S wheezing D/S
rales D/S
g. Alat bantu nafas
Ya
Tidak
Jenis .........................Flow ................Lpm
h.
Penggunaan WSD :
- Jenis : ....................................................................................................................
- Jumlah Cairan :.........................................................................................................
- Undulasi : .................................................................................................................
- Tekanan : .................................................................................................................
i.
Trakeostomy Ya
Tidak
................................................................................................................................................
j.
Lain-lain :

.......................................................................................................................
.........................
MASALAH KEPERAWATAN :
.................................................................................................................................................
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.................................................................................................................................................
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3. Sistem Kardiovakuler
a. Keluhan nyeri dada
ya
tidak
P : .....................................................................................
Q : .....................................................................................
R : .....................................................................................
S : .....................................................................................
T : .....................................................................................
b. CRT : ...............
c. Konjungtiva pucat
ya
tidak
d. 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
: ..........................
Lainlain : ...............................................................................................................................................
..
.................................................................................................................................................
MASALAH KEPERAWATAN :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Sistem Persarafan
a. Kesadaran
composmentis
apatis
somnolen
sopor
koma
GCS :
b. Pupil
isokor
anisokor
c. Sclera
Anikterus
Ikterus
d. Konjungtiva Ananemis
Anemis
e. 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 :
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5. Sistem Perkemihan (B4)
a.
Kebersihan genetalia :
Bersih
Kotor
b.
Sekret :
Ada
Tidak
c.
Ulkus :
Ada
Tidak
d.
Kebersihan Meatus uretera :
Bersih
Kotor
e.
Keluhan Kencing
Ada
Tidak
Bila ada jelaskan :
....................................................................................................................................................
....................................................................................................................................................
f.
Kemampuan berkemih
Spontan
Alat bantu, sebutkan : ...................................................................

Jenis : ........................................................................................
Ukuran : ........................................................................................
Hari Ke: ........................................................................................
g.
Produksi urine : ...........................ml/jam
Warnah
: ...............................
Bau
: ...............................
h.
Kandung kemih
:
Membesar
Ya
Tidak
i.
Nyeri Tekan
:
Ya
Tidak
j.
Intake Cairan :
Oral :....................cc/hari
Parenteral :
..............cc/hari
k.
Balance Cairan
: ..................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
o. Lain-lain : .....................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
MASALAH KEPERAWATAN :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
6. Sistem Pencernaan
a. TB
: ............. cm
BB : ..............kg
b. IMT
: .............
Interpretasi : .........................................
c. LLA
: .............
MASALAH KEPERAWATAN :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
d. Mulut :
Bersih
Kotor
e. Mukosa mulut :
Lembab
Kering
Merah
stomatitis
f. Tenggorokan Nyeri telan
Sulit menelan
Pembesaran Tonsil
Nyeri Tekan
g. Abdomen
Supel
Tegang nyeri tekan, lokasi :
Luka operasi
Jejas
lokasi :
Pembesaran hepar
ya
tidak
Pembesaran lien
ya
tidak
Ascites
ya
tidak
Drain
Ada
Tidak
- Jumlah
: ......................
- Warna
: ......................
- Kondisi area sekitar insersi : .....................................
Mual
ya
tidak
Muntah
ya
tidak
Terpasang NGT
ya
tidak
Bising usus :..........x/mnt
h. BAB :........x/hr, konsistensi : lunak
cair
lendir/darah
konstipasi
inkontinensia
kolostomi
i. Diet
padat
lunak
cair
Diet Khusus : ......................................................................................................................
Nafsu Makan
Baik
Menurun
Frekuensi :...............x/hari
jumlah:............... jenis : .......................
Lain lain : ..........................................................................................................................
MASALAH KEPERAWATAN :
....................................................................................................................................................
....................................................................................................................................................

....................................................................................................................................................
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7.
a.

b.
c.

Sistem Penglihatan
Pengkajian segmen anterior dan posterior
Orbita Dextra
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

Orbita Sinistra

Keluhan nyeri
Ya
Tidak
Luka opreasi Ada
Tidak
Tanggal operasi
: ........................
Jenis Operasi
: ........................
Lokasi
: ........................
Keadaan
: ........................
d.
Pemeriksaan penunjang lain
..........................................................................................................................................................
e.
Lain .........................................................................................................................
........................
.........................................................................................................................................................
.........................................................................................................................................................
MASALAH KEPERAWATAN
.........................................................................................................................................................
.........................................................................................................................................................
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8.
Sistem pendengaran
a.
Pengkajian segmen dan posterior
b.
Aurcicula
:
c.
MAE
:
d.
Membran Tympani :
e.
Rinne
:
f.
Webber
:
g.
Swabach
:
h.
Tes audiometri
:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
i.
Keluhan nyeri
Ya
Tidak
j.
Luka opreasi Ada
Tidak
Tanggal operasi
: ........................
Jenis Operasi
: ........................
Lokasi
: ........................
Keadaan
: ........................
k.
Alat bantu dengar : .......................................................
l.
Lainlain. ......................................................................................................................................
.......................................................................................................................................................
MASALAH KEPERAWATAN
.......................................................................................................................................................

.......................................................................................................................................................
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9. Sistem Muskuloskeletal dan Integumen (B6)

a.
Kekuatan otot

b.
c.
d.
e.
f.

g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.

Pergerakan sendi
bebas
terbatas
Kelainan ekstremitas
ya
tidak
Kelainan tlg. belakang
ya
tidak
Fraktur
ya
tidak
- Jenis :..............................................................
Traksi/spalk/gips
ya
tidak
- Jenis : ............................................
- Beban : ............................................
- Lama pemasangan : ...........................................
Penggunaan spalk/gips
ya
tidak
Keluhan nyeri :
ya
tidak
Sirkulasi perifer : ...........................................
Kompartemen sindrom
ya
tidak
Kulit
ikterik sianosis
kemerahan
hiperpigmentasi
Akral
hangat panas
dingin
kering
basah
Turgor
baik kurang
jelek
Odema:

Ada

Tidakada

Lokasi

Luka operasi : jenis :.............

luas : ...............
bersih
kotor
Tanggal operasi
: ..................
Jenis operasi
: ..................
Lokasi
: ..................
Keadaan
: ..................
Drain
:
Ada
Tidak
Jumlah
: ...................................................
Warna
: ...................................................
Lain-lain
: ...............................................................................................................
.................................................................................................................................................
MASALAH KEPERAWATAN :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
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10.
a.

Sistem Integumen
Penilaian risiko decubitus :

Aspek yang dinilai

PERSEPSI
SENSORI
KELEMBABAN
AKTIVITAS
MOBILISASI
NUTRISI
GESEKAN &
PERGESERAN

1
TERBATAS
SEPENUHNYA
TERUS MENERUS
BASAH
BEDFAST
IMMOBILE
SEPENUHNYA
SANGAT BURUK
BERMASALAH

KRITERIA YANG DINILAI

3
3
SANGAT
KETERBATASAN
TERBATAS
RINGAN
SANGAT LEMBAB
KADANG-KADANG
BASAH
CHAIRFAST
KADANG-KADANG
JALAN
SANGAT
KETERBATASAN
TERBATAS
RINGAN
KEMUNGKINAN
ADEKUAT
TIDAK ADEKUAT
POTENSIAL
TIDAK
BERMASALAH
MENIMBULKAN
MASALAH

NILAI
4
TIDAK ADA
GANGGUAN
JARANG BASAH
LEBIH SERING
JALAN
TIDAK ADA
KETERBATASAN
SANGAT BAIK

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

b.
c.
d.
e.
f.
g.

Warna : ...........................................................
Pitting edema : +/- grade : ..............................
Ekskoriasis : ya
tidak
Psoriasis
:
ya
tidak
Urtikaria
:
ya
tidak
Lainlain : ............................................................................................................................
..............................................................................................................................................
MASALAH KEPERAWATAN
..............................................................................................................................................
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11. Sistem Endokrin
a. Pembesaran kelenjar tyroid
ya
tidak
b. Pembesaran kelenjar getah bening
ya
tidak
c. 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

Tidak
Jika Ya
- Tahun : ..........................
- Lokasi : .........................
- Lain-lain : .....................................................................................................
.......................................................................................................................

MASALAH KEPERAWATAN :
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................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

G. PENGKAJIAN PSIKOSOSIAL
1. Persepsi klien terhadap penyakitnya
Cobaan Tuhan
Hukuman
2. Ekspresi klien terhadap penyakitnya
Murung
Gelisah
Tegang
3. Reaksi saat interaksi
kooperatif
4. Gangguan konsep diri
ya

Lainnya
Marah/menangis
tak kooperatif
tidak

curiga

MASALAH KEPERAWATAN :
...............................................................................................................................................
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...............................................................................................................................................
...............................................................................................................................................
H. PENGKAJIAN SPIRITUAL
a.
b.

Kebiasaan beribadah
Sebelum sakit
sering kadang-kadang tidak pernah
Selama sakit
sering kadang-kadang tidak pernah
Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

MASALAH KEPERAWATAN :
...............................................................................................................................................
...............................................................................................................................................
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I.
PERSONAL HYGIEN
a.

Kebersihan diri :

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
b.
-

Kemampuan klien dalam pemenuhan kebutuhan :

Mandi
:
Dibantu seluruhnya
dibantu sebagian
Ganti pakaian :
Dibantu seluruhnya
dibantu sebagian
Keramas
:
Dibantu seluruhnya
dibantu sebagian
Sikat gigi :
Dibantu seluruhnya
dibantu sebagian
Memotong kuku:
Dibantu seluruhnya
dibantu sebagian
Berhias
:
Dibantu seluruhnya
dibantu sebagian
Makan
:
Dibantu seluruhnya
dibantu sebagian

mandiri
mandiri
mandiri
mandiri
mandiri
mandiri
mandiri

MASALAH KEPERAWATAN :
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J. PEMERIKSAAN PENUNJANG(Laboratorium, radiologi, EKG, USG)

K. TERAPI

Tuban,.................................
Perawat Primer,

(.............................................)

ANALISA DATA
DATA

ETIOLOGI

MASALAH

DIAGNOSA KEPERAWATAN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

INTERVENSI
No

Diagnosa Keperawatan

Tujuan/
Kriteria Hasil

Tgl/jam

Intervensi

IMPLEMENTASI DAN EVALUASI

Rasional

DIAGNOSA

IMPLEMENTASI

JAM/TGL

EVALUASI SOAP