FORM ASESMEN AWAL IGD 2.docx

RUMAH SAKIT ISLAM GONDANGLEGI Jl.Hayam Wuruk No.66 Gondanglegi Malang 65174 Telp.(0341)879047-879879-878593 Fax.(0341)878593 Email:[email protected]

LABEL IDENTITAS

STATUS PENGKAJIAN GAWAT DARURAT Unjungan Pasien Baru Lama Warganegara WNI WNA Agama:............ ................. ............... ......... Pendidikan :.......... ................ ................. ................. ................. ............... ................. ... Cara Datang / Rujuk: Sendiri Rujukan.................. ................. ............... . Tiba di RSI Gondanglegi ........................................................................................................................................ Tanggal : ................................................. ........................................................................................................................................ Jam datang : ......... ................. .......WIB ........................................................................................................................................ Jam dilayani : .............. ................. ..WIB ..... Jam periksa : .............. ................. ..WIB Transportasi waktu datang : Ambulan 118 Ambulance lain Kendaraan lain Jenis kasus : Bedah Non Bedah Kebidanan Anak Resusitasi : Ya Tidak Penyebab cidera / keracunan : Kecelakaan Lalu Lintas Kecelakaan Rumah Tangga Kecelakaan Kerja .............. ............. ................. ............ Tempat Kejadiaan : ............. ................... ............... .................. ........ ............... ................. ....... / ............... .. Jam : .......... ..............WI B Aktivitas :.................................................................................................................................................................................... Keluhan Utama:......................................................................................................................................................................................... Tanda-tanda vital : GCS : E:........V:.. ......M:........ Pupil :............. ...mm/.......... ...mm Reflek Ca haya :........... ... / ................. TD : .............. ../............ mmHg Nadi :.................x/menit, :...... ...........x/menit, reguler / irreguler Suhu :.......... ....... °C RR : ............ ..... x/menit SpO2:............. % Akral: hangat / dingin / kering / basah CRT: < 2 dtk / > 2 dtk ALERGI TERHADAP :............................................................................................................................................................................ Assesmen psikologi Takut terhadap terapi/pembedahan *) Marah/tegang Sedih Tidak mampu menahan diri Gelisah *Bila ada gangguan,lakukan pengkajian Restrain

P1 GCS Airway  Suara nafas abnormal Breathing  RR  SPO2  Retraksi Circulation  Tekanan darah   Nadi  CRT  Akral  Suhu  Luka bakar 

30% Gr 3> 5%

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

     

< 40 85%-90% Ringan Sistolik > 200 < 50 / > 150 < 2 detik Dingin / hangat >40% Gr 2A/2B < 30% Trauma listrik

18-20 dewasa   94% 

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

Dalam batas normal

Gr I

Assesmen Nutrisi  BB :...........................Kg/gr TB;............................. Lingkar kepala: ......................cm (khusus khusus pediatrik )  Gangguan pemenuhan kebutuhan nutrisi : Ya Tidak   Apakah pasien mengalami penurunan/peningkatan*)BB yang tidak dir encanakan/tidak diinginkan? Ya,...........................Kg/gram*) Tidak Assesmen sosial dan ekonomi  Pekerjaan ..........................................................  Peran dalam keluarga Penanggung jawab ekonomi Kepala Keluarga Budaya keluarga yang mempengaruhi pola kesehatan Tidak ada Ada  Jelaskan..................................................................................................................................................................................... Suku Bangsa Jawa Madura ................. ........... .............. ................. ............. Adat /Budaya yang mempengaruhi pola kesehatan.................................................................................................................. Pembiayaan saat di rumah sakit Bayar Sendiri Asuransi Swasta Perusahaan BPJS ............ .............. .   Pengaruh terhadap ekonomi saat pasiwen dirawat Ada ......................... ........... Tidak ada Petugas Triase

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PENGKAJIAN KEPERAWATAN (Diisi Oleh Perawat) Auto anamnese  Nama : Hubungan: 1. Informasi didapat dari Hetero anamnese Jalan tanpa bantuan 2. Cara Masuk Jalan dengan bantuan: Kursi roda Tempat tidur dorong lainnya................. .......... Riwayat Penyakit Sekarang .................................................................................................................................................................................................................... .................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... .................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... ..................................................................................................................................................................................................................... Riwayat Penyakit Dahulu Riwayat Pengobatan

 No

Nama obat

Cara pemberian

Waktu pemberian terakhir

Obat diteruskan Ya

Ket

Tidak

Skala nyeri ( Beri tanda √ ) INTENSITAS NYERI “WONG BAKER FACES PAIN RATING SCALE” DAN “NUMERIC RATING SCALE” (NRS) UNTUK ANAK ≥ 6 TAHUN DAN DEWASA

Pengkajian Wajah Kaki Aktivitas Menangis Bersuara

Skala FLACC(Face,Legs,Activity,Cry,Consolability)untuk anak < 6 tahun 0 1 2 Tersenyum/tidak ada exspresi Terkadang menangis/menarik Sering menggetarkan khusus diri dagu&mengatupkan rahang Gerakan normal/relaksasi Tidak tenang/tegang Kaki dibuata menendang/menarik diri Tidur,posisi normal,mudah Gerarakan Melengkungkan  bergerak menggeliat,berguling,kaku  punggung/kaku/menghentak Tidak menangis(bangun/tidur) Menegerang,merengek-rengek Menangis terusmenerus,terhisak,menjerit Bersuara normal/tenang Tenang bila dipeluk,digendong Sulit untuk menenangkan atau diajak bicara

Nilai

Total skor Pengkajian fungsi: Aktivitas sehari-hari Mandiri Dengan bantuan Pengkajian dan intervensi resiko jatuh (Get Up and Go Test) a. Cara berjalan pasien  Tidak seimbang/sempoyongan/limbung Ya Tidak  Jalan dengan menggunakan alat bantu(kruk,kursi roda,tripot,orang lain) Ya Tida k b. Menopang saat akan duduk   Tampak memegang pinggiran kursi/meja/benda lain sebagai penopang saat akan Ya Tidak  Hasil : Tidak resiko (tidak ditemukan a& b) Tidak beresiko = tidak ada tindakan Resiko rendah (ditemukan salah satu dari a/b) Resiko Rendah = Edukasi Resiko Tinggi (ditemukan a&b) Resiko tinggi = Pasang pitakunin g dan edukasi Pengkajian resiko dekubitus  Apakah pasien menggunakan kursi roda atau mebutuhkan bantuan? Ya Tidak  Apakah ada inkontensia urine atau alvi ? Ya Tidak  Apakah ada riwayat dekubitus atau riwayat dekubitus? Ya Tidak  Apakah pasien di atas 65 tahun ? Ya Tidak Khusus anak  Apakah ekstremitas dan badan tidak sesuai dengan usia perkembangannya? Ya Tidak Apabila salah satu jawaban adalah “ya”.maka lakukan edukasi pencegahan dekubitus Status kehamilan Tidak hamil Hamil,Gravida :.........................Para:.. ................. .......Abortus:...... ............. ........HPHT:....... ............... Perawat yang mengkaji

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III.PENGKAJIAN MEDIS Pemeriksaan doter,jam: .............................. .WIB Subyektif: .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. Obyektif: .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. Pemeriksaan penunjang EKG :.............................................................................................................................................................................. Radiologi :.............................................................................................................................................................................. Laboratorium :.............................................................................................................................................................................. Assessment Dignosa kerja :......................................................................................................................................................................... ................................................................................................................................................................................................................. Diagnosa banding:........................................................................................................................................................................... .................................................................................................................................................................................................................. Planning :Penatalaksanaan/Pengobatan/Rencana tindakan .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. .................................................................................................................................................................................................................. Tulbak

Edukasi Tgl/  jam

Materi edukasi

Uraian tambahan

Evaluasi

Tanda tangan Pasien/klg

Edukator 

Penyakit,penyebab,tanda,dan gejala(DX:................................) Hasil pemeriksaan Tindakan medis Komplikasi Farmasi Manajemen nyeri ................................................... ................................................... ................................................... Gondanglegi,......................................

....................................... ( Tanda tangan dan nama dokter)

MASALAH KEPERAWATAN DAN EVALUASI MASALAH KEPERAWATAN Penuruann kesadaran Kejang Ketidak efektifan/bersihan jalan nafas Sesak  Nyeri Gangguan hemodinamika Gangguan integritas kulit Gangguan keseimbangan cairan dan elektrolit Peningkatan ushu tubuh ................................................................................... PEMBERIAN OBAT/INFUS Jam Nama obat/infus Dosis

TINDAKAN Jam

EVALUASI

Rute

Diperiksa oleh

Tindakan

Diberikan oleh

Nama &TTD

KONDISI PASIEN SAAT PINDAH/PULANG DARI UGD Tanda-tanda vital : GCS : E:........V:........M:........ Pupil :.............. ..mm/.............mm Reflek Cahaya :.............. / ................ . TD : .............. ../............ mmHg Nadi :.............. ...x/menit, reguler / irreguler Suhu :................. °C RR : ................. x/menit SpO2:............. % Akral: hangat / dingin / kering / basah CRT: < 2 dtk / > 2 dtk TINDAK LANJUT Boleh pulang Menolak MRS MRS di ruang............ ................ ........................... ............... ............. Dirujuk, ke.................................................Alasan dirujuk:............................................................................................................... Meninggal DOA DOR Jam............. ................WB Pendidikan kesehatan pasien pulang: Makan.minum obat teratur Jaga kebersihan luka Diet .................................................................... Nama /Tanda Tangan Dokter Nama /Tanda Tangan Perawat

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....................................................... Nama /Tanda Tangan Keluarga

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