Format Askep Gadar..

ASUHAN KEPERAWATAN KRITIS/EMERGENCY PADA Tn/Ny……DENGAN…………………..DISERTAI …………… DI RUANG IGD RSUD DR MOEWARDI SURAKARTA

A. PENGKAJIAN

Tanggal Masuk

:........................................... :................................................. ......

Tanggal Pengkajian

: ……………………………….

I. Identitas Klien

 Nama

: ……………………………….

Umur 

: ……………………………….

Jenis Kelamin

: ……………………………….

Alamat

: .......................................... ................................................. .......

Diagnosa Medis

:........................................... :.................................................. .......

 No. RM

: .......................................... ................................................. .......

II. Identitas Penanggung Jawab

 Nama

: .......................................... ................................................. .......

Umur

: .......................................... ................................................. .......

Jenis Kelamin

: .......................................... ................................................. .......

Alamat

: .......................................... ................................................. .......

Hub. Dengan Klien

: .......................................... ................................................. .......

a. PRIMARY SURVEY 

CIRCULATION

 Nadi :

Teraba

Tidak terbara

 Nadi :......X/Menit, Perdarahan :

Irama nadi :

Ada

Ya

Tidak teratur 

Tidak ada, tempat perdarahan :................................. :.................................

Perfusi / CRT :...... Sianosis :

Teratur

Tidak 

Tekanan Darah : ..............mmHg Suara Jantung :............................. :.............................



AIRWAY

Look ( Melihat obstruksi jalan nafas ) Obstruksi jalan nafas :

Ada

Tidak ada

 J ika ada berupa : Sekret

Darah

Benda asing

Lidah jatuh ke belakang

Listen ( Mendengarkan suara jalan nafas ) Gurgling

Snoring

Crowing

Feel ( Meraba ) Hembusan udara :

Hidung

Mulut

Deviasi trakhea :.................................... 

BREATHING Look (Lihat pergerakan dada)

Pengembangan dada : Sesak nafas

Simetris,

tidak simetris

Retraksi intercosta

Jejas di dada

Cuping hidung

Distensi vena leher 

Luka terbuka di dada

Listen ( Mendengarkan suara pernafasan )

Vesikuler

Bronkhovesikuler

Whezzing

Ronchi

Bronkhial

Krekles

Trakheal

Stridor 

Feel ( Meraba )

Krepitasi Perkusi : 

Nyeri tekan Sonor,

hipersonor,

dulness

DISABILITY

Kesadaran :

Alert

Kesadaran : GCS

Verbal respon

Composmentis

Apatis

Pain respon Somnolent

Unresponsible Sopor

Coma

: .............. Mata :............, Motorik :..........., Verbal :...........

Pupil

:

Isokor

Miosis

cahaya :....................... Papil edema :

Ada

Lateralisasi :

ya,

Tidak ada tidak 

Pin

Medriasis, reaksi terhadap



EXPOSURE

Jejas : Lesi :

ada, ada,

tidak ada, tempat jejas :...................................................... tidak ada, tempat lesi :..........................................

Kelainan bentuk :....................................  Nyeri :............................ 

Folley cateter

.............................................................................................................................. 

Gastric tube

............................................................................................................................. 

Heart monitoring dan oxymetri

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

b. SECUNDERY SURVEY 



Keadaan Umum

Tekanan Darah

: .........................................

 Nadi

: .........................................

RR

: .........................................

Suhu

: .........................................

Anamnesa …………………………………………………………………………………

…………………………………………………………………………………

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…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

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Keluhan

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

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Obat-obatan

.............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. 

Makanan

.............................................................................................................................. .............................................................................................................................. 

Penyakit penyerta

.............................................................................................................................. .............................................................................................................................. ............................................................................................................................. 

Alergi

.............................................................................................................................. .............................................................................................................................. .............................................................................................................................. 

Kejadian

.............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. 

Tubes and finger in every orifice

Lubang hidung :.......................... Lubang telinga :.......................... Lubang anus :.............................. Lubang vagina :.............................. 

Pemeriksaan kulit kepala Inspeksi : 

Laserasi : ............................



Kontusio :............................



Luka termal :..........................



Perdarahan :...............................

Palpasi : 

 Nyeri tekan :...............................



Fraktur :......................................



Wajah



Mata Inspeksi :















Cornea :.................................



Pupil :...................................



Racon eyes:..........................

Hidung 

Pembengkakan :.................................



Krepitasi / fraktur :............................

Zygoma 

Pembengkakan :.................................



Krepitasi / fraktur :...........................

Telinga 

Keutuhan membrantimpani :...........................



Hemotimpanium :..............................



Tanda batle sign :................................

Rahang atas 

Stabilitas rahang :........................



Krepitasi / fraktur :.........................



Pembengkakan :............................



Deformitas :..................................

Rahang bawah 

Stabilitas rahang :........................



Krepitasi / fraktur :.......................



Pembengkakan :...........................



Deformitas :.................................

Vertebra servikalis / Leher Inspeksi 

Jejas :................



Deviasi trakhea....................



Pemakaian otot pernafasan tambahan :...........................

Palpasi 





Deformitas :.............................



Pembengkakan :..........................

Torak  

Jejas :.......................



Luka terbuka :.................













 Nyeri tekan :...........................

 Nyeri tekan :........................ Krepitasi :.................................

Paru-paru 

Inspeksi :........................................



Palpasi :.........................................



Perkusi :..........................................



Auskultasi :.....................................

Jantung 

Inspeksi :......................................



Palpasi :........................................



Perkusi :.........................................



Auskultasi :...................................

Abdomen 

Inspeksi :............................................



Auskultasi :........................................



Perkusi :.............................................



Palpasi :..............................................

Pelvis 

Kestabilan posisi :..............................



Jejas :..................................................



 Nyeri tekan :........................................



Pembengkakan :.................................





Krepitasi / fraktur :............................



Deformitas :.........................................

Ekstremitas Inspeksi : 

Laserasi :.....................................



Perdarahan :...............................



Pembengkakan :............................



Deformitas :..................................

Palpasi :





 Nyeri tekan :...............................



Krepitasi :...................................



Kekuatan otot :...............................

Punggung 

Jejas :............................



Pembengkakan :.........................



Deformitas :...............................



 Nyeri tekan :..............................



Fraktur :....................................

c. PEMERIKSAAN DIAGNOSTIK  

Pemeriksaan Laboratorium .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ..............................................................................................................................

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Pemeriksaan Rotgen .............................................................................................................................. ..............................................................................................................................

.............................................................................................................................. ...... 

Pemeriksaan EKG .............................................................................................................................. .............................................................................................................................. ..............................................................................................................................

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Pemeriksaan CTScan/MRI .............................................................................................................................. .............................................................................................................................. ..............................................................................................................................

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Pemeriksaan USG .............................................................................................................................. .............................................................................................................................. ..............................................................................................................................

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Pemeriksaan yang lain .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ............

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Therapy ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ...