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ASUHAN KEPERAWATAN GAWAT DARURAT

Nama/Usia
Jenis kelamin
Alamat
Nomor register
MRS
Tanggal Pengkajian
Diagnosa medis
Keluhan
Keadaan Umum

: Tn. I/ 49 tahun
: Laki-laki
: Jl. Belitung Darat G.AA, Banjarmasin
: 1-14-24-XX
: 5 Maret 2015
: 5 Maret 2015
: STEMI + CHF
: Pasien mengeluhkan sesak dan batuk sejak 2 hari yang lalu nyeri pada bagain dada, demam sejak 4 hari yang
lalu, nyeri tekan pada bagian ulu hati nafsu makan menurun dan kepala terasa pusing.
: Pasien tampak sesak, pasien tampak meringis sambil memegangi daerah dadanya.

PRIMARY ASSESMENT
A. AIRWAY (JALAN NAFAS)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

B. BREATHING (NAFAS)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

DO:
- Pasien tampak sesak
- TD: 110/90 mmHg
- N: 116 x/mnt
- RR: 40 x/mnt
- T: 38,2C
- SPO2 : 95%
DS:
Pasien mengeluhkan
sesak nafas
Pasien mengeluhkan
nyeri dada

Pola nafas tidak efektif


b.d

C. CIRCULATION (SIRKULASI)
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

D. DISABILITY : AVPU
TEMUAN
ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

E. EXPOSURE
TEMUAN

ANALISA MASALAH

PERENCANAAN

IMPLEMENTASI

WAKTU

EVALUASI

SECONDARY ASSESMENT
1. Keadaan umum:

2. History:
a) S (Signs & Symptom): .

.
b) A (Allergies): ..
.
c) M (Medication): ..

d) P (Past Medical History):

.
e) L (Last Meal, Last Menstrual):

f)

E (Events): ..

3. Subjektif
Nyeri Dada: tidak terkaji
S : .
O : .
C : .
R : .
A : .
T : .
E : .
S : .
Nyeri Abdomen: tidak terkaji
P : .
Q : .

R : .
S : .
T : .

4. Objektif:
Observasi tanda-tanda vital dan SaO2
TTV :
BP
= mmHg
HR
= x/menit
RR
= x/menit
T
= 0C
SaO2
=

5. Pemeriksaan Head To Toe:


No.
1.

BAGIAN
Kepala

TEMUAN
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2.

Wajah

3.

Servikalis Dan
Leher

4.

Toraks

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5.

Abdomen

6.

Pelvis

7.

Ekstremitas

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8.

Bagian
Punggung

9.

Neurologis

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PEMERIKSAAN PENUNJANG
1. Laboratorium
Pemeriksaan
HEMATOLOGI
Hemoglobin
Lekosit
Eritrosit
Hematokrit
Trombosit
RDW-CV

Hasil
.
..
.
..
.
..
.

Nilai Rujukan

Satuan

Metoda

14,00 - 16,00
4,0 - 10,5
3,90 5,50
37,00 47,00
150 450
11,5 14,7

gr/dL
ribu/uL
juta/uL
vol %
ribu/uL
%

Colorimetric
Impedance
Impedance
Analyzer Calculates
Impedance
Analyzer Calculates

..
.
..
.
..
MCV, MCH, MCHC
MCV
MCH
MCHC

HITUNG JENIS
Gran %
Limfosit %
MID %
Gran #
Limfosit #
MID #

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

80,0-97,0
27,0-32,0
32,0-38,0

fl
pg
%

Analyzer Calculates
Analyzer Calculates
Analyzer Calculates

50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0

%
%
%
ribu/ uL
ribu/ uL
ribu/ uL

Impedance
Impedance
Impedance
Impedance
Impedance
Impedance

KIMIA
Glukosa darah puasa
Hati
SGOT
SGPT
Alumin
Ginjal
Ureum
Kreatinin
Elektrolit
Natrium
Kalium
Clorida
Faal Lemak Dan
Jantung
LDH
CKMB

.
..
.
..
.
..
.
..
.
..
4.1
.
..
.
..
.
..
.
..
140.7
3.6
106.0
619
22

2.

Foto
Hasil foto thorax (rontgen) :

<200

mg/ dL

GOD-PAP

0-46
0-45
3.5-5.5
10-50
0.6-1.2

u /l
u/l
g/dl
mg/dl
mg/dl

135-146
3,4-5,4
95-100

mmol/l
mmol/l
mmol/l

IFFC
IFFC
Biuret
Modif-berhelot
Jaffe
ISE
ISE
ISE

225-450
0-24

mmol/l
mmol/l

ISE
ISE

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CTR= a + b x 100% =
C
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Hasil CT Scan :
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Kesimpulan:

3. EKG :

Interpretasi EKG :