Вы находитесь на странице: 1из 11

PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND 2017

BAGIAN KEPERAWATAN GAWAT DARURAT

FAKULTAS KEPERAWATAN UNAND

FORMAT PENGKAJIAN

Nama Mahasiswa : .ISTIQAMAH YULIAS Tanggal Praktek : ..........................

No BP : 1741313063 Tempat Praktek : ..........................

Nama Pasien : ............................................... Umur : ....................................... L/P

I. Pengkajian Primer

A: B:

C: D:

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

E:

II. Data Demografi

Nama Lengkap : ........................................................ Tanggal masuk RS : ..................

Tempat/tgl lahir : ........................................................ Status perkawinan : ..................

Agama : ........................................................ Suku : ..................

Pendidikan : ........................................................

Pekerjaan : ........................................................ Lama bekerja : ..................

Alamat : ........................................................................................................................

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

Sumber Informasi : ............................................................................................................

Keluarga terdekat yang dapat dihubungi:

Nama : .......................................................

Pendidikan : ....................................................... Pekerjaan : ..........................

Alamat : ........................................................................................................................

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

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

III. Status Kesehatan Saat Ini

Alasan Kunjungan/keluhan utama:

Faktor pencetus:

Lamanya keluhan: .................................................................. Mendadak / Bertahap

Faktor yang memperberat:

Upaya yang dilakukan untuk mengatasi:

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

Diagnosa Medik:

.......................................................................... Tanggal .......................................

.......................................................................... Tanggal .......................................

.......................................................................... Tanggal .......................................

IV. Riwayat Kesehatan yang lalu

Penyakit yang pernah dialami (jenis penyakit, lama dan upaya mengatasi)

Alergi : ........................................................................................................................................

Kebiasaan : merokok / kopi / alkohol / lain-lain ..........................................................................

Obat-obatan yang sering digunakan (nama dan frekwensi)

Pola Nutrisi :

Berat badan : ........................................................ Tinggi badan : ...........................

Frekwensi makan : ............................................................................................................

Jenis makanan : ................................................................................................

Makanan yang disukai : ................................................................................................

Makanan yang tidak disukai : ............................................................................................

Nafsu makan dalam 6 bulan terakhir : Baik / Sedang / Kurang

Perubahan berat badan 6 bulan terakhir : ..................... Kg Bertambah / Berkurang


Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

Pola Eliminasi :

Buang air besar

Frekwensi : ...................................... Waktu : .....................................

Warna : ...................................... Konsistensi : .........................

Kesulitan : ................................................................................................

Buang air kecil

Frekwensi : ...................................... Warna : .........................

Kesulitan : ................................................................................................

Pola tidur dan istirahat

Lama tidur : .................................................. Waktu : .....................................

Kesulitan dalam hal tidur : ................................................................................................

Pola aktivitas dan latihan

Kegiatan dalam pekerjaan : ...............................................................................................

Olah raga rutin (jenis dan frekwensi) :

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

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

Kegiatan di waktu luang : ..................................................................................................

Keluhan dalam beraktivitas : .............................................................................................

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

Pola Bekerja

Jenis pekerjaan : ...................................................... Lama bekerja : ......................

Jadwal kerja : ...................................................... Jumlah jam kerja : .....................

V. Riwayat Keluarga

Genogram beserta penyakit yang dialami oleh anggota keluarga lain

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

VI. Pengkajian Sekunder

Kepala

Inspeksi / Palpasi : ............................................................................................................

Keluhan : ............................................................................................................

Mata

Fungsi penglihatan : .................................................. Palpebra : Terbuka / tertutup

Ukuran pupil : .......................................................................... Isokor / Unisokor

Akomodasi : .......................................................................... Isokor / Unisokor

Konjungtiva : .................................................... Sklera : .....................................

Edema Palpebra : ............................................................................................................

Keluhan : ............................................................................................................

Telinga

Fungsi Pendengaran : ............................................ Fungsi keseimbangan : .............

Keluhan : ............................................................................................................

Hidung dan sinus

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

Pembengkakan : ................................................. Pendarahan : ............................

Keluhan : ...........................................................................................................

Mulut dan tenggorok

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

Keadaan gigi : ...........................................................................................................

Keadaan membran mukosa : ............................................................................................

Kesulitan menelan : ............................................................................................


Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

Leher

Inspeksi / palpasi : ............................................................................................................

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

Thoraks

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

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

Perkusi Paru : ............................................................................................................

Perkusi Jantung : ............................................................................................................

Auskultasi Paru : ............................................................................................................

Pola ventilator : ............................................................................................................

Deskripsi ventilator : ..........................................................................................................

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

Auslkultasi Jantung : ..........................................................................................................

Gambaran EKG : ................................................. JVD : .........................................

Sirkulasi

Frekwensi nadi : ......................................... Sa O2 : ..................................................

Tekanan darah : ........................... MAP : ........................ CVP : .................

PA Sistolik : ........................... PA Diastolik : ................ PAP : .................

Suhu tubuh : ........................... Suhu ekstremitas : ............................................

Sianosis : Bibir / kuku ...................... Pucat : ...................................................

Turgor : ............................................................................................................

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

Abdomen

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

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

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

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

Jenis diet : .......................................... Nafsu makan : .....................................

Pengeluaran NGT : ............................................................................................................

Frekwensi BAB : .......................................... Konsistensi feses : ................................

Keluhan makan dan BAB : ................................................................................................

Frekwensi BAK : ........................................ Volume Urin : .....................................

Penggunaan kateter : .................................... Hematuri : .....................................

Keluhan BAK : ............................................................................................................

Riwayat Kehamilan : ..........................................................................................................

Perdarahan pervaginam : ................................................................................................

Keluhan sistem reproduksi : ..............................................................................................

Ekstremitas

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

Masa otot : ............................................ Tonus otot : ...........................................

Kekakuan : ............................................ Kejang : .................................................

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

VII. Data Laboratorium

VIII. Hasil Pemeriksaan Diagnostik lain

Istiqamah Yulias

1741313063
PRAKTEK PROFESI KEPERAWATAN GAWAT DARURAT
FAKULTAS KEPERAWATAN UNAND 2017

IX. Pengobatan

X. Kesimpulan

XI. DAFTAR PUSTAKA

Istiqamah Yulias

1741313063

Вам также может понравиться