•

FORMAT PENGKAJIAN
KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWAtU UMRl

.7'?.'.!../J-.1r..~
. . . . . . ..... ....
A. INFORMASI ~MUM
. A (\ '1,1,VI
Nama : 'lr...- Umur
ninggatlahlr . : -~-~.... Jenl5 tcelamln •...1 kf-''. -•{_, ~• •..... ..
Suku Bangsa : ... M~~~Y.............. .. Tanggal Masuk : ?..f(.1..1:-.!..Y?.~~.... .
Tanggal Pengkajia~ : .~t,/t'!--:/.~. ~]-;. .. . Dari/Rujukan
Dlagnosa Medik '. Nomor Medical Record · _O_\l_l_ tt. ~&......... ..

································•························································································· .............................. .
PENGKAJIA$ PRIMER

Airway , : V..~.\~~. . . k.~~. ~.::£.~,.... 5:.~.~.~~.~~.~ .. \~~f;'- cul~ """"'""\o~-t: .- Jct .. " vt q
Breathing
. ····················································································
circor~"tion :·1~. :.. . .'.". . .~.~l~.~:>.+~:.... t.~~~.~~~·J, °' 1-cl A.F\c, \:l(L- :~, 4 l,\,.u-.·
Disability = .b.~g~r~. . . .....~.½+~~ ................... .
Exposure : .~~.!.~~.\~~.::..... \~i.~ . . . ...1..:..?.~..~.(':'...
Foley kateter = . . k~R.~.~.~..........r.\j.... .. .
Gastric Tube = ..~~.~1}~.~Y:;.~l<':j.........G.~r~~·~··· ~~!.! . . . .
Heart Monitor :..... \.~~.....\~~~.?.~.......\:\~~.....

PENGKAJ~ SEKUNDER

C. RIWAYAT KE~EHATAN SEBELUMNYA

.V,~J.\~...... ...~.~~.,:.k.\~~·.........\l~.~.~~.~... .... ......~.P. ...:t ············

..\i....,~ ........................ .
.. ........ ............ ........ .. ... ... ........ ......... ..... , ................... .. ...... .................. .. .. ............ .. ..................... ... .... .
·······•......................................................................................................... , .................................. .....

26
 I

I
D. RIWAVAJ KELUARGA

l;d.~.~....+:~.t :':. . . .~~.\i:~·.......\?.~~.~.~~. .t,.':.~ ....s..~.~.~. . . ...t~?.'.~

.............................. j.......................................................................................... ................................
I
.........................................................................................................................................................

E, PEMERIKSA1NFISIK
• Tanda-tanda vital:
I
TD : \.'./& ..; .f~mmHg
·1 SUhu

Nadl : ~~... x/menit Pemafasan : ll.... x,'menit

• 1inggi Badan : !.. ..lJ~)...... cm Berat Badan : .... .G.~........ Kg

I, Kepala

Rambut
: ~njang/per.dek/tanpa rambut/kotor/mudah '?ntok/gatal-gatal
.~~~kL ....:\::-~~.~~.........
Lajn-lain~: \Q.f~.~~...t..1~'¾t.. "&, t lc. ct_,½o,~~
11

Mata : "l'-
: lkter1k/ml riasls/pakal kacamata/contact lens/gangguan pengllhatan

!..tin-lain: ~?.:h .... .5\~.~~.~.~.... \~ ....J::~J.~.. i.( ~ln' le H / ~v.~J ~...._ ~~t~-l -l-
Hldung : Aerdarahan/slnusitls/gangguan penduman/malformasi/terpasang NGr

laln~ain : .Jl\\1/.!t,...\,!<::~:.\c. --~~1.M1......-~~:....~• \,,""" , ~""l '}., _ ~<><t..• ~-• l ·

Mulut : ~otor/bau/terpasang ETT/Gudel/perdarahan/lidah kotor/gangguan
pehgecapan

ta;n-1,1n : !/\!'!:\!!l:. .J~~,. )11.1.Si~.,.... \1,/s, h:..... \ <i..~ -1, .

Gigi : (ligi palsu/kotor/kawat gigi/karies/tidak ada gigi
i

Lain-lain : ·.fui.~{ ..... ~tc;c.~f,. .... \c~t\~~.t-J,,. ......

Telinga
: ~rclarahan/terpasang alat bantu dengar/ lnfeksi/ gangguan pendengaran

lain-lain :i4\~~. . 5~~.~L.

J~r.) .... A.;.f.:~"'-O..k , \.t
J.c-\.C- ~cl~ j J" "'
II. Leher 'a .11,.1 cvv~. q\(""" • .

: PembesaraH KGB/kaku kuduk/terpasang trakeostom1/JVP : ............. .... .. ..

Lain-lain: .. .. .. ....... s.~~.~.t~.~f..~... 'f~i
III. Dada
: Inspeksi : .d..~.~~... ..t.~~v.~.~. ...... . .. ol~ ~--.."'-
Palpasi : .. . . ...Y.\.. .....(.k~t~J~.\~~-~~~. . IJ,,-.. ~c. ~~cl, k¼r -t-
Perkusi : -~-(\bSr ...... ..r. ....:... ........................ ..
27
 I
I

IV, Tangan ,:tA~~~::~:·:~;~~::~:-~::;~;:;:ha~r/

Lain-lain: 3\~. . . . ~~.r:. . /
e
....
d~a .€d:t1M .. (,)

V. Abdomen :Inspe~i: \.~f~.~.~.1:-.....~~f..~......~~.!.t.... !->.P,... .... t.~ ~d.\. -COe"""\ ~ft.: (). l.,,l,1.o."1
Palpa~i :.\-.(~7.~.... ...~t:L .. .. J~~"' (.It}
i ,t\. <
Perk~ : .......~.~.~¼-.1.. ................................................ .

Ausku~sl : .... ......~.~-5....... ~~.~-L.........

VI. Genitalia : Perd~tahan/terpasang kateter/trauma/malformasl/ menstruasi/infeksi

Lain-1aln _ : .. . .. ~.t~~)......... \::.~.t~~:..

VII. Kaid : FraJr/edema/malformasl/luka/infeksi/keganasan/slanosfs/dlngin ·•

Lain-lJin :\:.~£:....... . .:. . . . .\;f. (A tv.._ \,~""', 'h

..
!V\ C-~ t-) • I t.q (,\,H
VIII. Punggung : Lo~osis/kiposis/skoliosls/luka/dekubitus/infeksi

Lain-l~in .\'Ai~j "'"'j .... ~\.v,..<,~~~- ... a_ct .. c\-tM t~ \r'f.

Hasil- Pemel'iksaett ~torium- datt Diagnostilt

···························································································································•················
································•.•········································································································

Medikasi /obat-obatjan yang diberikan saat inl

.\Y"J..·:.~~.~..t:-}.~~~............................................... ··············· ............................... ··········· .. .

.t~ .....~~\:: ........................................................................................ .....................
~'!-:-£-.:....~.!:f:~....................................................................................................................
Diagnosa keperawa~n

1...... ...... 0..\.~.~.:.................................................................................................. .. .

2........................................................................................................................................ .
3-....................................................................................................................................... ..
4 ........................................................................................................................................
5.........................................................................................................................................

Pekanbaru, ................... .

Mahasiswa

28
 ANALISA DAT A \
/
DATA MASALAH

'
\
ETIOLOGI
KEl'EllAWATAN
. \)., ·--~C:.')\-«M. \/\>.~.(,\": t,"' . . -k ~t.Wj -\C.. \ ...\--

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FORMAT UJIAN KGD PROFESI FKP-UNRI

I. PENGKAlIAN
A. IDENTITAS
1. Identitas Klien ··
Nama :l V\ ·t.
Umur :4r ~c-'-'v""
Agama : I ) \c. "'°'
Pendidikan : C-,\\1\~
Pekerjaan : iuw'-' \o A.~v."'--"'
Suku/ bangsa : ()"-"""
Diagnosa medis :v L.
Tanggal masuk RS : \'\, ,1)),,1,
Tanggal pengkajian : t,S° \1., ) 1.b"-1-
No. Medrek : ()\I\~~ 1.-l\
Alamat : ) \ - "'- r... v-") '-f--- ; Sw\1" ""-"'
2. ldentitas penanggung jawab
Nama : -t"' .
Umur : 4t \'-'-'w
Agama : \ \ '"""
Pendidikan : (\\/\f'J<
Pekerjaan
Suku/ bangsa .
: V,"'~"""'
: \J'-'.<\. . .
½c."'~"'-"'-'"'
Hubungan dengan khen . : '\-t\J"A.~~ / f2.."\;.-"' ~~e..
Alamat :u , \. V\ -./\~"-
,. L . , 11 j
, , "\lllw~v-.
B. KELUHAN UTAMA
.....~).~\..... \~.~·····2·~'.:~... ....!~<:~.~~ .. ... .k.~~. :.\~ . . . . .
... .... ~\.:-.h~.....h~.':-....... .. .:\.~.~0.~.t::\......\~.\::: .. l~.~~\.~ .....<l.~.V:.. ~.~~\c~\l
.. tfl Vl~"}\""V\ .... l~~.,, c............................................................................................................... .
·············································································································· .•······································

PENGKAJIAN PRIMER
A:irway : .~~,~.'M......~~tY.1.::-£.~>... .. Ste.11~t~~1..~-J.. k. ~J, ~w..\l ..t-"' ~...J.'" o"'c..-"' "'-f•
Breathing : ~':'.\\~ ...~~l!,-.';1.:i~~..-:~.:-.-r. ...J>.1...Y.1.~r.:\ \c.1,1"'-v\ .(~'1--:. 1.3~/V'l..-c.Y';.\-)
Circulation :(tr.. .1... 1.0..~~.1,1. .. H.f .. ..~.~'.".'/~.~.~:1-
Disability : f..~1":".f ....... .....P.~~~">--~.tli\,\-:>
Exposure : :lei.J.~r~. ..C~M.~ ....v.~.~.~. . .~~~~.- - - \c.~ ..\... ~v\e- vo\?~~ ~ti~\
Foley kateter : ¾4.~.t-~.:\-·\t~J?~~. .l~~.~..\:.:{~t,-<r"
Gastric tube r£..".:'-...........~).!r.,J,...~•
: ....... ~::':.•.......
Heart monitor : ... ~.\}~~ ....... ....~.~~_j_~IM.~~,,-

38
C. Pengkajian terkofus (slstem yang terganggu)
~--~-"'.J."-----k•-t-~------~1~ _ _ hi..t•.r.e:1 _____ ~\ J_a_,_A~~-\-~.1~\::'o___0t\Y/_,:1-_ --·
1

.... ....... ~~::.......... ~~.~·'······························fj··················"··· ................. .

.:. . . . l.t~::~....l~!.t~.ia~::.._.~[""l:':.l......:tl::......r . · · ""•"·-·-· · •"-•
...:-... ... ~~.':',j.~~~':.'...... ......... f;..~t. .... ......~.';~.....Y.~!i\~....
...~Y..:..1~::.J.?.1/.~~.~l.~':::::~:~.......................................................................
................ ..:..0.~.. ...............................................................................
................. ..:. .. ...............................................................................

............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

.....................................................................................................................
································································································································
................................................................................................................................
································································································································

39
 ., ... ....... ......... ,,,., ....................................................................................................
, ,

································································································································
································································································································

D. Diagnosa keperawatan, data penunjang, tindakan dan rasional

1.. ....f!:~ ................................................. .
2... .. .. ~\.:\ ·
3.......................................................................... .
4.......................................................................... .

40
 FORMAT
ANAUSA DATA

No Data Etiologi Masalah Keperawatan

I· \:h: ~t..)\L\f\ \.f<l.tVI)®"' \ le.\) W\ C..~~ 1]°\f ,~_.. N~ 1 ~1· c. \ ..\·

"'-"jt; 0. ''7 ~~r-"'

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4
I
FORMAT
RENCANA ASUHAN KEPERAWATAN
Nama Pasien : \\J\·'>
Ruang Nama Mahaslswa
:\b'Q NIM
No. M.R.
:t}\111c_, ·u.\

No Dlagnosa Tujuan/ Krlterla Hasll

keperawatan lntervensi

'\.,. ~M'~jvW- \V\~tlbr;

\'-\ ~J.\' \
I CATATAN PERKEMBANGAN

Nama klien : V\.

Diagnosa med is : \J \.,

Ruang rawat : \b

Waktu Diagnosa Tanda

(Tgl/Jam) Implementasi Evaluasi (SOAP) tangan
Keperawatan
t,V1,,/ 1A)'L"' ~~<.,; lµi~. - YV\<,\c..~11~ ~<-W'~Wj (fr,,-
J"'-"': \",-OD
q_~
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· ·Ob
l~"""'b,'\ SUr--\ti\ \ot-..~-4"'\J'\-'
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... w..t\/\~1w,v\"~ \t~\
n\t½.;,·' ¾~">th•

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s :.-,"'~'""' \}>..~c.l(c,.~ .....,_
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(J'"'"'-'· V\i_~\/\JIO\\ ..."' 'Ill\,
(9~ .oo - ~jC\\.l\t~ \\)\1,,
>~t\o-.'-\ c\\\c \_u~ .. V\

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