YAYASAN RUSTIDA

AKADEMI KESEHATAN RUSTIDA

Program Studi DIII Keperawatan
Alamat : Jalan RSU. Bhakti Husada
Telp. (0333)821495, Fax: (0333)821193
KRIKILAN – GLENMORE – BANYUWANGI
FORMAT PENGKAJIAN ASUHAN KEPERAWATAN
GAWAT DARURAT (GADAR)

Nama Mahasiswa : …………….....................

Semester/Tingkat :...........................................
NIM : …………………………
Tempat Praktek :..........................................

Ruangan : ………………………………
No. Reg : ………………………………….
Tgl Pengkajian : ………………………………
Jam : ………………………………….

DATA KLIEN

A. DATA UMUM
1. Nama inisial klien : .........................................................
2. Umur : .........................................................
3. Alamat : .........................................................
4. Agama : .........................................................
5. Tanggal masuk RS/RB : .........................................................
6. Nomor Rekam Medis : .........................................................

B. PENGKAJIAN PRIMER:
1. Airway/jalan nafas (paten/tidakjika tidak, penyebabnya, dan suara nafas)
..................................................................................................................................
..................................................................................................................................
2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, frekuensi dan irama, jenis pernafasan, bantuan
nafas, dll)
....................................................................................................................................................
....................................................................................................................................................
b. Palpasi (focal fremitus, dll)
...................................................................................................................................................
....................................................................................................................................................
c. Perkusi (pembesaran paru, dll)
....................................................................................................................................................
....................................................................................................................................................
d. Auskultasi (suara nafas)
....................................................................................................................................................
....................................................................................................................................................
3. Circulation
a. Vital sign:
1) Tekanan darah : ....................................... mmHg
2) Nadi : ....................................... x/menit
 3) Suhu : ........................................ oC
b. Capilarry refill : ........................................ detik
c. Sianosis/pucat : ………………………………………………………………………
d. Akral : ………………………………………………………………………
e. Kelembapan : ………………………………………………………………………
f. Turgar : ………………………………………………………………………
Lain-lain : ………………………………………………………………………

4. Disability
a. GCS/AVPU : ………………………………………………………………………
b. Pupil(diameter,isokor/anisokor, respon cahaya)
....................................................................................................................................................
....................................................................................................................................................
c. Gangguan motorik : ………………………………………………………………………
d. Gangguan sensorik : ………………………………………………………………………

5. Expousere/Environment/Event
a. Adanya trauma pada daerah :
………………………………………………………………………………………………
………………………………………………………………………………………………
b. Adanya jejas/luka pada daerah :
……………………………………………………………………………………………
……………………………………………………………………………………………
c. Ukuran luka/jenis luka :
……………………………………………………………………………………………
……………………………………………………………………………………………
d. Kedalaman luka :
……………………………………………………………………………………………
……………………………………………………………………………………………
e. Lain2 (Px. Penunjang/proses kejadian) :
……………………………………………………………………………………………
……………………………………………………………………………………………

C. SECONDERy SURVEY
6. Five Intervensi/Full Of Vital Sign
a. Five Intervensi
1) EKG :
2) Cateter :
3) NGT :
4) Sp O2 :
5) Laboratorium :
b. Full Of Vital Sign
1) TD/MAP :
2) Nadi :
3) Suhu :
4) Rr :
5) BB :
7. Give Comfort/beri kenyamanan
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

8. History dan Head to toe

a. History
1) Keluhan utama :
..........................................................................................................................................
..........................................................................................................................................
2) Riwayat pengakit sekarang :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
3) Makan-minum terakhir :
..........................................................................................................................................
4) Riwayat medikasi :
..........................................................................................................................................
.....
5) Pengalaman pembedahan :
..........................................................................................................................................
6) Alergi terhadap obat :
..........................................................................................................................................
7) Riwayat penyakit dahulu :
..........................................................................................................................................
8) Riwayat penyakit keluarga :
..........................................................................................................................................
..........................................................................................................................................
b. Head to Toe
1) Kepala
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
2) Leher
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
3) Dada
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
..........................................................................................................................................
4) Abdomen
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
5) Ekstremitas
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6) Kulit/integument
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

D. TERAPI MEDIS
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………

Mengetahui, ............................., ……………….20….

Clinical Instructure/CI/Dosen Pembimbing Mahasiswa

(………………………………..) (………………………………..)
 ANALISIS DATA

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................
NO DATA ETIOLOGI MASALAH
 DAFTAR PRIORITAS MASALAH KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................

Prioritas
Tanggal Muncul DIAGNOSA KEPERAWATAN Tanggal Teratasi
Ke-
1

4
 RENCANA INTERVENSI KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................

Tujuan/ Intervensi/
NO Diagnosa
Nursing Outcome Nursing Intervension Rasional Tindakan
Dx Keperawatan
Criteria (NOC) Criteria (NIC)
 IMPLEMENTASI KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................

Hari, Tanggal Jam Dx Kep Implementasi & Respon

 EVALUASI KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................

Hari, Tanggal Jam Dx Kep Evaluasi

1 S:

O:

A:

P:

2, dst
 CATATAN PERKEMBANGAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................

Hari, Tanggal Jam SOAPIE

*Kolom ini digunakan untuk dokumentasi keperawatan hari Ke-2 dst.