form pengkajian gadar ugd
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FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT
Nama Mahasiswa :.........................................................................................................Semester/Tingkat :.........................................................................................................Tempat Praktek :.........................................................................................................Tanggal Pengkajian :.........................................................................................................
DATA KLIEN
A. DATA UMUM1. Nama inisial klien : .........................................................2. Umur : .........................................................3. Alamat : .........................................................4. Agama : .........................................................5. Tanggal masuk RS/RB : .........................................................6. Nomor Rekam Medis : .........................................................7. Bangsal : .........................................................
B. PENGKAJIAN PRIMER:1. Airway (jalan nafas)
..................................................................................................................................
..................................................................................................................................2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, bantuan nafas, dll)........................................................................................................................................................................................................................................................
b. Palpasi (total fremitus, dll)........................................................................................................................................................................................................................................................
c. Perkusi (pembesaran paru, dll)........................................................................................................................................................................................................................................................
d. Auskultasi (suara nafas)........................................................................................................................................................................................................................................................
3. Circulationa. Vital sign:
1) Tekanan darah :2) Nadi :3) Suhu :4) Respirasi :
b. Capilarry refill :c. Akral :
4. Disabilitya. GCS
E: ..... M: ........ V: ......b. Pupil :c. Gangguan motorik :d. Gangguan sensorik :
C. PENGKAJIAN 13 DOMAIN NANDA1. HEALTH PROMOTION
a. Kesehatan Umum:- Alasan masuk rumah sakit/keluhan utama:
......................................................................................................................
......................................................................................................................b. Riwayat masa lalu (penyakit, kecelakaan,dll):
............................................................................................................................
............................................................................................................................c. Riwayat pengobatan
No Nama obat/jamu Dosis Keterangan 1.2.3.
d. Kemampuan mengontrol kesehatan:- Yang dilakukan bila sakit : .........................................................................- Pola hidup (konsumsi/alkohol/olah raga, dll)
......................................................................................................................
......................................................................................................................
......................................................................................................................
e. Faktor sosial ekonomi (penghasilan/asuransi kesehatan, dll):............................................................................................................................ ............................................................................................................................
f. Pengobatan sekarang:No Nama obat Dosis Kandungan Manfaat 1.2.3.4.
2. NUTRITION a. A (Antropometri) meliputi BB, TB, LK, LD, LILA, IMT:
1) BB biasanya: .............. dan BB sekarang: ............2) Lingkar perut :3) Lingkar kepala :4) Lingkar dada :5) Lingkar lengan atas :6) IMT :
b. B (Biochemical) meliputi data laboratorium yang abormal:__________________________________________________________________________________________________________________________________________________________________________________________
c. C (Clinical) meliputi tanda-tanda klinis rambut, turgor kulit, mukosa bibir, conjungtiva anemis/tidak:__________________________________________________________________________________________________________________________________________________________________________________________
d. D (Diet) meliputi nafsu, jenis, frekuensi makanan yang diberikan selama di rumah sakit:
__________________________________________________________________________________________________________________________________________________________________________________________
e. E (Enegy) meliputi kemampuan klien dalam beraktifitas selama di rumah sakit: __________________________________________________________________________________________________________________________________________________________________________________________
f. F (Factor) meliputi penyebab masalah nutrisi: (kemampuan menelan, mengunyah,dll)__________________________________________________________________________________________________________________________________________________________________________________________
g. Penilaian Status Gizi__________________________________________________________________________________________________________________________________________________________________________________________
h. Pola asupan cairan__________________________________________________________________________________________________________________________________________________________________________________________
i. Cairan masuk__________________________________________________________________________________________________________________________________________________________________________________________
j. Cairan keluar__________________________________________________________________________________________________________________________________________________________________________________________
k. Penilaian Status Cairan (balance cairan)__________________________________________________________________________________________________________________________________________________________________________________________
l. Pemeriksaan AbdomenInspeksi :Auskultasi :Palpasi :Perkusi :
3. ELIMINATION a. Sistem Urinary
1) Pola pembuangan urine (Frekuensi , jumlah, ketidaknyamanan)____________________________________________________________________________________________________________________
2) Riwayat kelainan kandung kemih
____________________________________________________________________________________________________________________
3) Pola urine (jumlah, warna, kekentalan, bau)____________________________________________________________________________________________________________________
4) Distensi kandung kemih/retensi urine____________________________________________________________________________________________________________________
b. Sistem Gastrointestinal1) Pola eliminasi
____________________________________________________________________________________________________________________
2) Konstipasi dan faktor penyebab konstipasi____________________________________________________________________________________________________________________
c. Sistem Integument1) Kulit (integritas kulit / hidrasi/ turgor /warna/suhu)
____________________________________________________________________________________________________________________
4. ACTIVITY/RESTa. Istirahat/tidur
1) Jam tidur :2) Insomnia :3) Pertolongan untuk merangsang tidur:
____________________________________________________________________________________________________________________
b. Aktivitas 1) Pekerjaan :2) Kebiasaan olah raga :3) ADL
a) Makan :b) Toileting :c) Kebersihan :d) Berpakaian :
4) Bantuan ADL :5) Kekuatan otot :
6) ROM :7) Resiko untuk cidera :
____________________________________________________________________________________________________________________
c. Cardio respons1) Penyakit jantung :2) Edema esktremitas :3) Tekanan vena jugularis:4) Pemeriksaan jantung
a) Inspeksi :b) Palpasi :c) Perkusi :d) Auskultasi :
d. Pulmonary respon1) Penyakit sistem nafas :2) Penggunaan O2 :3) Kemampuan bernafas :4) Gangguan pernafasan (batuk, suara nafas, sputum, dll)
____________________________________________________________________________________________________________________
5) Pemeriksaan paru-parua) Inspeksi :b) Palpasi :c) Perkusi :d) Auskultasi :
5. PERCEPTION/COGNITION a. Orientasi/kognisi
1) Tingkat pendidikan :2) Kurang pengetahuan :3) Pengetahuan tentang penyakit:4) Orientasi (waktu, tempat, orang)
b. Sensasi/persepi1) Riwayat penyakit jantung :2) Sakit kepala :3) Penggunaan alat bantu :4) Penginderaan :
____________________________________________________________________________________________________________________
c. Communication 1) Bahasa yang digunakan :2) Kesulitan berkomunikasi :
6. SELF PERCEPTION a. Self-concept/self-esteem
1) Perasaan cemas/takut :2) Perasaan putus asa/kehilangan:3) Keinginan untuk mencederai :4) Adanya luka/cacat :
7. ROLE RELATIONSHIP a. Peranan hubungan
1) Status hubungan :2) Orang terdekat :3) Perubahan konflik/peran :4) Perubahan gaya hidup :5) Interaksi dengan orang lain :
8. SEXUALITY a. Identitas seksual
1) Masalah/disfungsi seksual :
9. COPING/STRESS TOLERANCE a. Coping respon
1) Rasa sedih/takut/cemas :2) Kemampan untuk mengatasi :3) Perilaku yang menampakkan cemas ;
10. LIFE PRINCIPLES a. Nilai kepercayaan
1) Kegiatan keagamaan yang diikuti :2) Kemampuan untuk berpartisipasi :3) Kegiatan kebudayaan :4) Kemampuan memecahkan masalah :
11. SAFETY/PROTECTION a. Alergi :b. Penyakit autoimune :c. Tanda infeksi :d. Gangguan thermoregulasi :e. Gangguan/resiko (komplikasi immobilisasi, jatuh, aspirasi, disfungsi
neurovaskuler peripheral, kondisi hipertensi, pendarahan, hipoglikemia, Sindrome disuse, gaya hidup yang tetap)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
12. COMFORTa. Kenyamanan/Nyeri
1) Provokes (yang menimbulkan nyeri) :2) Quality (bagaimana kualitasnya) :3) Regio (dimana letaknya) :4) Scala (berapa skalanya) :5) Time (waktu) :
b. Rasa tidak nyaman lainnya :c. Gejala yang menyertai :
13. GROWTH/DEVELOPMENT a. Pertumbuhan dan perkembangan :
D. DATA LABORATORIUM
Tanggal & Jam
Jenis Pemeriksaan
Hasil Pemeriksaan
Harga Normal
Satuan Interpretas
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