Format Pengkajian Gadar New 2012

FORMAT PENGKAJIAN KEPERAWATANGAWAT DARURAT

Pengkajian tgl. : Jam :MRS tanggal : No. RM :Diagnosa Masuk : Hari Rawat Ke :Ruangan/kelas :

A. IDENTITAS PASIENNama : Penanggung jawab biaya :Usia : Nama :Jenis kelamin : Alamat :Suku /Bangsa : Hub. Keluarga :Agama : Telepon :Pendidikan :Status perkawinan Pekerjaan :Alamat :

B. RIWAYAT PENYAKIT SEKARANG1. Keluhan Utama : .......................................................................................................................2. PENGKAJIAN PRIMER

A. Airway :

B. Breathing :

C. Circulation :

D. Disability :

E. Eksposure :

C. RIWAYAT PENYAKIT DAHULU1. Pernah di rawat ya, jenis : ....................... tidak2. Riwayat Penyakit Kronik dan Menular ya, jenis : ....................... tidak3. Riwayat Penyakit Alergi ya, jenis : ....................... tidak4. Riwayat Operasi ya, jenis : ....................... tidak

- Kapan : ...............................- Jenis Operasi : ...............................

5. Lain-lain :...................................................................................................................................................................................................................................................................................................................................................................................................................................................

PROGRAM STUDI S1 KEPERAWATANSEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN

KampusA : Jl. P. Diponegoro 17 Tuban (62315) | Telp. (0356) 321287 | Fax. (0356) 333237 | KampusB : Jl. LetdaSucipto 211 Tuban (62351) | Telp. (0356) 325789 | (0356) 712572 | Website.http://www.stikesnu.com | Email. [email protected]

D. RIWAYAT PENYAKIT KELUARGAya : ........................................ tidak

GENOGRAM

E. PERILAKU YANG MEMPENGARUHI KESEHATANPerilaku sebelum sakit yang mempengaruhi kesehatan

Alkohol ya tidakKeterangan ..........................................................................................................Merokok ya tidakKeterangan ..........................................................................................................Obat ya tidakKeterangan ..........................................................................................................Olahraga ya tidakKeterangan ..........................................................................................................

F. OBSERVASI DAN PEMERIKSAAN FISIK1. Keadaan Umum

Tanda-tanda vitalKeadaan umum baik sedang lemahS : ºC N : x/mnt TD : mmHgRR : x/mnt

MASALAH KEPERAWATAN :..................................................................................................................................................................................................................................................................................................

2. Sistem Pernafasana. RR : ...............................b. Keluhan : Sesak Nyeri waktu sesak Orthopnea

Batuk Produktif Tidak ProduktifSekret : .................... Konsistensi : .......................Warna : ................... Bau : ....................................

c. Pola nafas irama: Teratur Tidak teratur

d. Jenis Dispnoe Kusmaul Ceyne Stokes Lain-lain:

Pernafasan cuping hidung ada tidakSeptum nasi simetris tidak simetrisLain-lain :

e. Bentuk dada simetris asimetris barrel chestFunnel chest Pigeons chest

f. Suara napas vesiculer ronchi D/S wheezing D/S rales D/Sg. Alat bantu nafas Ya Tidak

Jenis .........................Flow ................Lpmh. Penggunaan WSD :

- Jenis : ....................................................................................................................- Jumlah Cairan :.........................................................................................................- Undulasi : .................................................................................................................- Tekanan : .................................................................................................................

i. Trakeostomy Ya Tidak................................................................................................................................................

j. Lain-lain :................................................................................................................................................

MASALAH KEPERAWATAN :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Sistem Kardiovakulera. Keluhan nyeri dada ya tidak

P : .....................................................................................Q : .....................................................................................R : .....................................................................................S : .....................................................................................T : .....................................................................................

b. CRT : ...............c. Konjungtiva pucat ya tidakd. Bunyijantung: Normal Murmur Gallop lain-lain

e. Iramajantung: Reguler Ireguler S1/S2 tunggal Ya Tidak

f. Akral: Hangat Panas Dingin kering Dingin basah

g. Siklus perifer Normal Menurun

h. JVP : ..........................

Lain-lain : ..................................................................................................................................................................................................................................................................................................

MASALAH KEPERAWATAN :................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Sistem Persarafana. Kesadaran composmentis apatis somnolen sopor koma

GCS :b. Pupil isokor anisokorc. Sclera Anikterus Ikterusd. Konjungtiva Ananemis Anemise. Istirahat/Tidur : .................................................f. Nyeri tidak ya, skala nyeri : lokasi :g. Refleksfisiologis: patella triceps biceps lain-lain:

h. Reflekspatologis: babinskybudzinsky kernig lain-lain

i. Keluhan Pusing O ya O Tidak

MASALAH KEPERAWATAN :...............................................................................................................................................................................................................................................................................................................................................................................................................................................................

5. Sistem Perkemihan (B4)a. Kebersihan genetalia : Bersih Kotorb. Sekret : Ada Tidakc. Ulkus : Ada Tidak d. Kebersihan Meatus uretera : Bersih Kotore. Keluhan Kencing Ada Tidak

Bila ada jelaskan :........................................................................................................................................................................................................................................................................................................

f. Kemampuan berkemihSpontan Alat bantu, sebutkan : ...................................................................

Jenis : ........................................................................................Ukuran : ........................................................................................

Hari Ke: ........................................................................................g. Produksi urine : ...........................ml/jam

Warnah : ...............................Bau : ...............................

h. Kandung kemih : Membesar Ya Tidaki. Nyeri Tekan : Ya Tidakj. Intake Cairan: Oral :....................cc/hari Parenteral : ..............cc/harik. Balance Cairan : ..................................................................................................................

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

....................................................................................................................................................o. Lain-lain : .....................................................................................................................................

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

....................................................................................................................................................MASALAH KEPERAWATAN : ............................................................................................................................................................................................................................................................................................................................................................................................................................................................

6. Sistem Pencernaana. TB : ............. cm BB : ..............kgb. IMT : ............. Interpretasi : .........................................c. LLA : .............MASALAH KEPERAWATAN :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................d. Mulut : Bersih Kotore. Mukosa mulut : Lembab Kering Merah stomatitisf. Tenggorokan Nyeri telan Sulit menelan

Pembesaran Tonsil Nyeri Tekang. Abdomen Supel Tegang nyeri tekan, lokasi :

Luka operasi Jejas lokasi :Pembesaran hepar ya tidakPembesaran lien ya tidakAscites ya tidakDrain Ada Tidak- Jumlah : ......................- Warna : ......................- Kondisi area sekitar insersi : .....................................Mual ya tidakMuntah ya tidakTerpasang NGT ya tidakBising usus :..........x/mnt

h. BAB :........x/hr, konsistensi : lunak cair lendir/darah

konstipasi inkontinensia kolostomii. Diet padat lunak cair

Diet Khusus : ......................................................................................................................Nafsu Makan Baik Menurun Frekuensi :...............x/hari jumlah:............... jenis : .......................Lain –lain : ..........................................................................................................................

MASALAH KEPERAWATAN :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

7. Sistem Penglihatana. Pengkajian segmen anterior dan posterior

Orbita Dextra Orbita SinistraVisus

PalpebraConjunctiva

KorneaBMDPupilIris

LensaTIO

b. Keluhan nyeri Ya Tidakc. Luka opreasi Ada Tidak

Tanggal operasi : ........................Jenis Operasi : ........................Lokasi : ........................Keadaan : ........................

d. Pemeriksaan penunjang lain..........................................................................................................................................................

e. Lain ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................

MASALAH KEPERAWATAN ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

8. Sistem pendengarana. Pengkajian segmen dan posteriorb. Aurcicula :c. MAE :d. Membran Tympani :e. Rinne :f. Webber :g. Swabach :h. Tes audiometri :

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

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

.......................................................................................................................................................i. Keluhan nyeri Ya Tidak

j. Luka opreasi Ada TidakTanggal operasi : ........................Jenis Operasi : ........................Lokasi : ........................Keadaan : ........................

k. Alat bantu dengar : .......................................................l. Lain-lain. ......................................................................................................................................

.......................................................................................................................................................MASALAH KEPERAWATAN.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Sistem Muskuloskeletal dan Integumen (B6)a. Kekuatan otot

b. Pergerakan sendi bebas terbatasc. Kelainan ekstremitas ya tidakd. Kelainan tlg. belakang ya tidake. Fraktur ya tidak

- Jenis :..............................................................f. Traksi/spalk/gips ya tidak

- Jenis : ............................................- Beban : ............................................- Lama pemasangan : ...........................................

g. Penggunaan spalk/gips ya tidakh. Keluhan nyeri : ya tidaki. Sirkulasi perifer : ...........................................j. Kompartemen sindrom ya tidakk. Kulit ikterik sianosis kemerahan hiperpigmentasil. Akral hangat panas dingin kering basahm. Turgor baik kurang jelekn. Odema: Ada Tidakada Lokasi

o. Luka operasi : jenis :............. luas : ............... bersih kotorp. Tanggal operasi : ..................q. Jenis operasi : ..................r. Lokasi : ..................s. Keadaan : ..................t. Drain : Ada Tidaku. Jumlah : ...................................................v. Warna : ...................................................

Lain-lain : ................................................................................................................................................................................................................................................................

MASALAH KEPERAWATAN :..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

10. Sistem Integumena. Penilaian risiko decubitus :

Aspek yang dinilai KRITERIA YANG DINILAI NILAI1 3 3 4

PERSEPSI SENSORI

TERBATAS SEPENUHNYA

SANGAT TERBATAS

KETERBATASAN RINGAN

TIDAK ADA GANGGUAN

KELEMBABAN TERUS MENERUS BASAH

SANGAT LEMBAB KADANG-KADANG BASAH

JARANG BASAH

AKTIVITAS BEDFAST CHAIRFAST KADANG-KADANG JALAN

LEBIH SERING JALAN

MOBILISASI IMMOBILE SEPENUHNYA

SANGAT TERBATAS

KETERBATASAN RINGAN

TIDAK ADA KETERBATASAN

NUTRISI SANGAT BURUK KEMUNGKINAN TIDAK ADEKUAT

ADEKUAT SANGAT BAIK

GESEKAN & PERGESERAN

BERMASALAH POTENSIAL BERMASALAH

TIDAK MENIMBULKAN

MASALAH

NOTE : Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko mengalami dekubitus (Pressure ulcers)(15 or 16 =low risk, 13 or 14 = moderate risk, 12 or less= high risk)

TOTAL NILAI

b. Warna : ...........................................................c. Pitting edema : +/- grade : ..............................d. Ekskoriasis : ya tidake. Psoriasis : ya tidakf. Urtikaria : ya tidakg. Lain-lain : ............................................................................................................................

..............................................................................................................................................MASALAH KEPERAWATAN ..........................................................................................................................................................................................................................................................................................................................................................................................................................................

11. Sistem Endokrin a. Pembesaran kelenjar tyroid ya tidakb. Pembesaran kelenjar getah bening ya tidakc. HiperglikemiaYaTidakHipoglikemia Ya Tidak

d. Kondisi kaki DM :

- Luka gangrene Ya Tidak

- Jenis Luka : .....................................................

- Lama luka : .....................................................

- Warna : .....................................................

- Luas Luka : .....................................................

- Kedalaman : .....................................................

- Kulit Kaki : ..............................................- Kuku kaki : ..............................................- Telapak kaki : ..............................................- Jari kaki : ..............................................- Infeksi : Ya Tidak

- Riwayat luka sebelumnya : Ya Tidak

- Tahun : ..................................................

- Jenis Luka : ..................................................

- Lokasi : ..................................................

- Riwayat amputansi sebelumnya : Ya TidakJika Ya

- Tahun : ..........................

- Lokasi : .........................

- Lain-lain : ............................................................................................................................................................................................................................

MASALAH KEPERAWATAN :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

G. PENGKAJIAN PSIKOSOSIAL1. Persepsi klien terhadap penyakitnya

Cobaan Tuhan Hukuman Lainnya2. Ekspresi klien terhadap penyakitnya

Murung Gelisah Tegang Marah/menangis3. Reaksi saat interaksi kooperatif tak kooperatif curiga4. Gangguan konsep diri ya tidak

MASALAH KEPERAWATAN :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

H. PENGKAJIAN SPIRITUAL

a. Kebiasaan beribadah- Sebelum sakit sering kadang-kadang tidak pernah- Selama sakit sering kadang-kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................


I. PERSONAL HYGIENa. Kebersihan diri :

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

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

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

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

b. Kemampuan klien dalam pemenuhan kebutuhan :- Mandi : Dibantu seluruhnya dibantu sebagian mandiri- Ganti pakaian : Dibantu seluruhnya dibantu sebagian mandiri- Keramas : Dibantu seluruhnya dibantu sebagian mandiri- Sikat gigi : Dibantu seluruhnya dibantu sebagian mandiri- Memotong kuku: Dibantu seluruhnya dibantu sebagian mandiri- Berhias : Dibantu seluruhnya dibantu sebagian mandiri- Makan : Dibantu seluruhnya dibantu sebagian mandiri


J. PEMERIKSAAN PENUNJANG(Laboratorium, radiologi, EKG, USG)

K. TERAPI

Tuban,.................................Perawat Primer,

(.............................................)

ANALISA DATA

DATA ETIOLOGI MASALAH

DIAGNOSA KEPERAWATAN

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

INTERVENSINo Diagnosa Keperawatan Tujuan/

Kriteria HasilTgl/jam Intervensi Rasional

IMPLEMENTASI DAN EVALUASIDIAGNOSA IMPLEMENTASI JAM/TGL EVALUASI SOAP

Format Pengkajian Gadar New 2012

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