PENGKAJIAN GAWAT DARURAT

Nama : Umur : No. Reg :

Alamat : Jenis Kelamin : Dx. Medis:

Alasan Masuk IGD:

Tingkat Kesadaran : AVPU = GCS : E= V= M= Four Score =

Tanda Vital: TD :

Nadi :

RR :

Suhu :

Pengkajian Hasil yang didapatkan

Primary Survey

Circulation Nadi karotis :

Frekuensi :

Airway Sumbatan Jalan Nafas :

Listen : Suara Nafas :
Bunyi Nafas :
Feel :
Breathing Look : Gerakan dinding dada :
Disability GCS =
Kekuatan Otot =

Refleks Pupil =
Ukuran dan kesimtrisan pupil =

Exposure D = Deformity :
O = Open Wounds :
T = Tenderness :
S = Swelling :
Folley Kateter :

Kateter Produksi Urin : /jam

Gastric Tube Terpasang NGT :

Muntah :
EKG Letal / Non Letal
Gambaran

Secondary Survey

Trauma : Deformities & Discolorations

DCAP-BTLS Crepitus & Contusions
Abrasion & Avulsion
Penetrations & Punctures
Burns & Bruising
Tenderness & Temperature
Lacerations
Swelling & Symmetry

SAMPLE S – Signs/Symptoms (tanda/gejala tambahan)

 A – Allergies :
Jenis alergi :

M – Medications : pengobatan sebelumnya/obat yang dikonsumsi :

P – Past Illnesses :

L – Last Oral Intake (Last Menstrual Cycle) :

E – Events Leading Up To Present Illness/Injury

OPQRST Onset of the Event

Provocation or Palliation
Quality of the Pain
Region and Radiation
Severity
Time (history)

Diagnosa
No Intervensi Evaluasi
Keperawatan