ASUHAN KEPERAWATAN DI INSTALASI GAWAT

DARURAT

PENGKAJIAN
1. Identitas
a. Pasien
Nama : ………………………………(initial)
Umur :
………………………………………
Kelamin :
………………………………………
Pendidikan :
………………………………………
Pekerjaan :
………………………………………
Agama :
………………………………………
Alamat :
………………………………………
Tanggal/ Jam masuk RS : ………………
Tanggal/ Jam pengkajian : ……………….
Diagnosa medis :
……………….
b. Penanggungjawab
Nama :
………………………………………
Age :
………………………………………
Kelamin :
………………………………………
Religion :
………………………………………
Alamat :
………………………………………
Hub. Dengan pasien :
……………….

2. Keluhan Utama
 …………………………………………………………...

……………………………………………………………

3. Riwayat Penyakit
a. Riwayat Penyakit Sekarang
….……………………………………………………
….……………………………………………………
….……………………………………………………
b. Riwayat Penyakit Dahulu
….
…………………………………………………………
……………………………………………….
…………………………………………………………
.
c. Riwayat Penyakit Keluarga
….……………………………………………………
4. Primary Survey
a. Airway
Open and inspect – talking? tongue occluding
airway? loose teeth/foreign objects? secretions?
edema?
b. Breathing
Spontaneous? chest rise? normal rate?
accessory muscle use? abnormal skin color? soft
tissue or bone deformity? tracheal deviation?
JVD? Oxygen saturation?
c. Circulation
Pulse general rate & quality, Skin color,
temperature, external bleeding, normal skin temp
and moisture? good cap refill? Blood pressure?
d. Disability
What’s LOC using AVPU? GCS? normal pupils
(PERL)?
e. Exposure
Remove clothing? what’s body temp?

5. Secondary Survey
a. SAMPLE (MIVT)
b. Head To Hoe Assessment
Head and  Inspect for wounds, ecchymosis,
Face deformities, from nose & ears,
check pupils
 Palpate for tenderness, note bony
cuepitus, deformity
Neck  Remove anterior portion of cervical
collar to inspect & palpate the neck
 Inspect for wounds, ecchymosis,
deformities & distended neck veins
 Palpate for tenderness, note bony
crepitus, subcutaneous
emphysema & tracheal position
Chest  Inspect for breathing role & depth,
wounds, deformities, ecchymosis,
use of accessory muscles,
paradoxical movement
 Palpate for tenderness, note bony
crepitus, subcutaneous
emphysema & deformity
 Auscultate breath & head sounds
 DCAB BLS TIC
Abdomen  Inspect for wounds, distention,
and Flanks ecchymosis and scars
 Auscultate bowel sounds
 Palpate all four quadrants for
tenderness, rigidity, guarding,
masses and femoral pulses
 TIC
Pelvis and  Inspect far wounds, deformities,
Perineum ecchymosis, priapism, blood at the
urinary meatus or in the perineal
area
 Palpate the pelvis and anal
sphincter tone
 DCAB BLS TIC
Extremities  Inspect for erachymosis movement
 wounds and deformities
 Palpate for pulses, skin
temperature, sensation,
tenderness, deformities and note
bony crepitus
 DCAB BLS TIC

6. Examination Support
(Laboratory test, X-Ray, BGA etc)
7. Therapy
(Drug, Diet etc)

Data Analysis
Day/ Date/ Etiolog Simple
No Data Problem
Time y Pathway

Nursing Diagnoses
Ineffective airway related to ………………
Intervention
Nursing Nursing
Day/
No Outcomes Interventions Signature/
Date/
Dx Classification Classification Name
Time
(NOC) (NIC)

Implementation
Day/
Signature/
Date/ Implementation No. Dx Response
Name
Time
S:
O:

Evaluation
No Day/ Evaluation Signature/
Dx Date/ Name
 Time
S. Reason for seeking
care or other
information the patient
or family members tell
you
O. Factual, measurable
data, such as
observable signs and
symptoms, vital signs
or test value
A. Conclusion based on
subjective and
objective data and
formulated as patient
problems or nursing
diagnoses
P. Strategy for relieving
the patient’s problems,
including short-term
and long-term actions

Discharge Summary
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