Format Pengkajian Gawat Darurat

Nama : Umur : No. Reg :

…………………………… ………………………….. ……………………...
Alamat :………………......
Jenis Kelamin : Dx. Medis:
……………………………
…………………………… …………………………... ………………………
Alasan Masuk IGD:
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
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Tingkat Kesadaran : AVPU = …………..GCS =…………Four Score =………….

Tanda Vital: TD:……….mmHg Nadi:……..x/menit Suhu:……….0Celcius

RR………….x/menit

Pengkajian Hasil yang didapatkan

Primary Survey
Circulation Nadi karotis : ada / tidak
Frekuensi :………….
Airway Sumbatan Jalan Nafas : ada / tidak
Bunyi Nafas : stridor/gurgling/snoring
Breathing Look : Gerakan dinding dada : ada / tidak
Listen : Suara Nafas : ada / tidak
Feel : rasakan hembusan nafas

Disability GCS =……………

Kekuatan Otot =………………………………………………..

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Refleks Pupil=………………………………………………….
Ukuran dan kesimtrisan pupil:…………………………………
Exposure D = Deformity…………………………………………………..
…………………………………………………………………..
…………………………………………………………………..
O = Open Wounds……………………………………………....
…………………………………………………………………..
…………………………………………………………………..
T = Tenderness………………………………………………….
…………………………………………………………………..
…………………………………………………………………..
S = Swelling……………………………………………………..
…………………………………………………………………..
…………………………………………………………………..
Folley Kateter : ya/tidak
Kateter Produksi Urin……………….../jam
Gastric Tube Terpasang NGT :………..
Muntah : ya/tidak………jumlah………….cc
EKG Letal / Non Letal
Gambaran…………………………………………………........
…………………………………………………………………..
…………………………………………………………………..
Secondary Survey
Trauma : Deformities &
DCAP-BTLS Discolorations…………………………………………………..
…………………………………………………………………..
…………………………………………………………………..
…………………………………………………………………..
Crepitus &
Contusions……………………………………………………...
…………………………………………………………………..
…………………………………………………………………..
Abrasion &
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Avulsion………………………………………………………...
…………………………………………………………………..
…………………………………………………………………..
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Penetrations &
Punctures……………………………………………………….
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Burns &
Bruising…………………………………………………………
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
Tenderness &
Temperature…………………………………………………….
…………………………………………………………………..
…………………………………………………………………..
Lacerations……………………………………………………...
…………………………………………………………………..
…………………………………………………………………..
Swelling &
Symmetry……………………………………………………….
…………………………………………………………………..
…………………………………………………………………..
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SAMPLE S – Signs/Symptoms (tanda/gejala tambahan)
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
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A – Allergies : ada / tidak

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……………………………………………………………...
…………………………………………………………………..
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Region and
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Radiation……………………………………………………….
………………………………………………………………….
………………………………………………………………….
Severity…………………………………………………………
………………………………………………………………….
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Time
(history)………………………………………………………...
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….

Diagnosa
Intervensi Evaluasi
Keperawatan

1.

2.
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3.