PENGKAJIAN KEPERAWATAN GAWAT DARURAT
"Tgl / jam : 11– 08 - 2014 , 18.28 No RM : "
"105487 "
"Triage : hijau "
"Diagnosa Medis : DHF "
"Transportasi: Ambulan / Mobil pribadi /lain – lain : "
" I "Nama /Inisial : Ny. S "
"D "Suku/Bangsa : Indonesia "
"E "Jenis Kelamin : Perempuan Status "
"N "Perkawinan : belum kawin "
"T "Umur : 38 Th "
"I "Sumber Informasi : Tn .p "
"T "Agama : Hindu "
"A "Penanggung Jawab :Tn .p "
"S "Pendidikan : SMA "
" "Hubungan :orang tua "
" "Pekerjaan : Wiraswasta "
" "Pekerjaan : "
" "Alamat : Desa Tegak , kec. Klungkung Alamat : "
" "Desa Tegak , kec. Klungkung "
" "Kesadaran : composmetis "
" "Keluhan : Px datang dengan keluhan muntah , sesak nafas , pusing, "
" "panas sejak 3 hari yang lalu , susah menelan , batuk "
"A "Jalan Napas : tidak paten "
"I "Obstruksi : tidak ada "
"R "Suara Nafas : "
"W "Suspeck Cervical Injury : "
"A "Reflek Mual Muntah : ada "
"Y "Keterangan : pasien muntah -muntah , dengan volume 250 cc "
" "Masalah Keperawatan : ketidak efektifan pola nafas "
"B "Nafas : Spontan "
"R "Gerakan dinding dada : Simetris "
"E "RR : 27x / mnt "
"A "Sesak nafas : ada "
"T "Deviasi trakea : Tidak ada "
"H "Retraksi otot bantu nafas : tidak terkaji "
"I "Pernafasan cuping hidung : ada "
"N "Pernafasan : Pernafasan dada "
"G "Irama nafas : dangkal "
" "Pola nafas : Tidak teratur "
" "Jenis : "
" "Perkusi :Sonor "
" "Suara nafas : whezzing "
" "Masalah Keperawatan : ketidakefektifan pola nafas b/d hiperventilasi yang "
" "ditandai dengan sesak nafas , RR: 27 x / menit , ada pernafasan cuping "
" "hidung "
" "
"C "Nadi : teraba "
"I "Frekuensi : 83 x / menit "
"R "Tekanan darah : 100/-70 mmHg "
"C " "
"U "Pucat : Ya "
"L "Sianosis : Tidak "
"A "CRT : <2 detik "
"T "Akral : Hangat "
"I "Pendarahan : tidak ada "
"O "Turgor : Elastis "
"N "Rirawat kehilangan cairan berlebihan : Muntah "
" "Keterangan : pasien muntah, suhu "
" "tubuh pasien meningkat , penurunan tekanan darah "
" "Masalah Keperawatan : kekurangan volume cairan "
" D " Kesadaran : composmentis "
"I "GCS : E: 4 V:5 M:6 "
"S "Pupil : 3/3 miosis Isokor"
"A "Repleks Cahaya : positif "
"B "Repleks Fisiologis : "
"I "Repleks Patologis : "
"L "Kekuatan Otot : 555 555 "
"I "555 555 "
"T " "
"Y "Keterangan : "
" "Masalah Keperawatan : "
"E "Deformitas : "
"X "Contusio : "
"P "Abrasi : "
"O "Penetrasi : "
"S "Laserasi : "
"U "Edema : "
"R "Luka Bakar : (-) "
"E " "
" "Masalah Keperawatan : "
"F "Interprestasi EKG : "
"I " "
"V " "
"E " "
" " "
"I "Saturasi O2 : "
"N "Pemasangan NGT : tidak terpasang NGT "
"T "Hasil laboratorium : terlampir "
"E " "
"R " "
"V "Terapi Medis : "
"E "IVFD RL 20 tetes "
"S "PSIDI 2x "
"I "ONDANCENTRON 2x 1 mg "
" "MUCOLAX "
" " "
" " "
" "Keterangan : "
" "Masalah keperawatan : "
" "Nyeri : tidak terkaji "
" "O : R : "
" "P : S : "
"G "Q : T : "
"I " "
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" "Masalah keperawatan : "
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" "Mekanisme cedera ( trauma ) : "
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" "Sign / tanda dan gejala : "
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" "Alergi : "
" "Alergi tidak terkaji , keluarga pasien tidak tau pasien memiliki alergi atau"
" "tidak "
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" "Medication / pengobatan "
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" "Past medical history / riwayat penyakit sebelumnya : "
" "keluarga pasien mengatakan pasien memiliki riwayat sesak nafas sejak kecil "
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" "Last oral intake / makan terakhir "
" "bubur ayam "
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" "(Fokus pemeriksaan pada daerah trauma/sesuai kasus non trauma) "
" "Kepala dan wajah : "
" "Inspeksi : - kepala : tidak ada lesi, tidak ada nyeri tekan, tidak ada "
" "ketombe, persebaran rambut merata , warna rambut hitam "
" "Wajah : bentuk wajah simetris , tidak ada acne, mata simetris kanan dan kiri"
" ", konjungtiva ananemis, sclera anikterik , pupil 3/3 miosis isokor reflek "
" "kedip (+), reflek cahaya (+) , mukosa bibir kering. "
" "Leher : tidak ada edema , tidak ada bendungan vena jugularis , arteri "
" "karotis teraba "
"H " "
"E "Dada : "
"A "Inspeksi : bentuk dada simetris, tidak ada hyperpigmentasi, tidak ada lesi ,"
"D " "
" "Palpasi : tactil vokal premitus teraba "
"T "Perkusi : tidak terkaji "
"O "Auskultasi : Pul : whezzing (+) "
" "Kard : bj 1 bj 2 tunggal regular "
"T " "
"O "Abdomen dan pinggul : "
"E "I : abdomen simetris, bentuk datar , tidak ada lesi , "
" "A :peristaltic usus 9 kali permenit "
" "P : tidak terkaji "
" "P : tidak terkaji "
" " "
" " "
" "Pelvis dan perineum : "
" "Tidak terkaji "
" " "
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" " "
" "Ekstermitas : "
" "Atas : akral dingin , CRT kembali <2 detik , turgor kulit tidak elastis, "
" "nadi 83x/mnt ,pulsasi nadi lemah , infuse ditangan kanan "
" "Bawah : warna kulit pucat ,akral hangat , tidak ada varises vena, tidak "
" "ada lesi , CRT <2 detik "
" "Masalah keperawatan : "
" "Jejas : tidak terkaji "
" "Deformitas : tidak terkaji "
" "Tenderness : tidak terkaji "
" "Crepitasi : tidak terkaji "
" "Laserasi : tidak terkaji "
" "Keterangan : "
" "Masalah keperawatan : "
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"E " "
"N " "
"G " "
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" "Masalah keperawatan : "
ANALISA DATA DAN DIAGNOSA KEPERAWATAN GAWAT DARURAT
Nama Klien : Ny S No. RM : 105487
Umur : 10tahun Dx. Medis : DHF
TINDAKAN KEPERAWATAN GAWAT DARURAT
Nama klien : Ny . S No. RM : 10 5487
Umur/JK : 10tahun Dx. Medis : DHF
"NO "Tgl/jam "No. "Implementasi "Evaluasi "Paraf "
" " "Dx " " " "
"1 "11/08/14 " I "Mengobservasi tanda –tanda "Ds : pasien " "
" "18 : 30 " "vital pasien "mengatakan " "
" " " " "kepalanya masih " "
" " " " "sedikit pusing " "
" " " " "Do : - Ku lemah " "
" " " " "Td :110/70 mmHg " "
" " " " "N : 78x/menit " "
" " " " "R : 25x/ menit " "
" " " " "Suhu 37.4 oC " "
"2 "18.37 " " " " "
" " " " "Ds : pasien " "
" " " "memberikan posisi nyaman "mengatakan sesaknya" "
" " " "semi fowler "sedikit berkurang " "
" " " " "Do : - Ku lemah " "
" " " " "R : 25x/ menit " "
" " " " "Suhu 37.4 oC " "
" " " " "pasien terlihat " "
" " " " "lebih tennag " "
"3 "18.44 " " "pasien dalam posisi" "
" " " " "setengah duduk " "
" " " " "Ds : (-) " "
" " " " "Do : - Ku lemah " "
" " " "Mengauskultasi suara paru "suara paru " "
" " " " "terdengar whezzing " "
" " " " " " "
" " " " " " "
"4 "18.48 " " " " "
" " " " "Ds : (-) " "
" " " " "Do : - Ku lemah " "
" " " " "pasien terlihat " "
" " " " "lebih tenang " "
" " " "Memberikan terapi O 2 4 lt "pasien menggunakan " "
" " " "dengan nasal canule "nasal canule " "
" " " " "oksigen masuk 4 " "
"5 "18.56 " " "liter " "
" " " " " " "
" " " " "Ds : pasien " "
" " " " "mengatakan " "
" " " " "tangannya sakit " "
" " " " "kalau ditusuk untuk" "
" " " " "diinfuse " "
"6 "19.04 " "Memberikan terapi IVFD RL 20"Do : - infuse ada " "
" " " "tetes "di tangan kanan " "
" " " " "- infuse RL dengan " "
" " " " "tetesan 20 tetes " "
"7 "19.04 " " " " "
" " " " "Ds : pasien " "
" " " " "mengatakan masih " "
" " " " "merasa sedikit mual" "
" " " "Memberikan terapi " " "
" " " "Ondancentron 2x 1 mg "Do : px terlihat " "
" " " " "lemas " "
" " " " " " "
"8 "19.19 " " "Ds : pasien " "
" " " " "mengatakan mau " "
" " " "Menganjurkan minum air 1500 "menuruti nasehat " "
" " " "ml "yang diberikan " "
" " " " "Do : - KU lemah " "
" " " " "pasien mampu minum " "
" " " " "setengah botol akua" "
" " " " "sekitar 500ml air " "
" " " " " " "
"9 "19.23 " " "Ds : pasien masih " "
" " " " "mengatakan sedikit " "
" " " " "lemas dan pusing " "
" " " " "Do : - KU lemah " "
" " " "Mengobservasi TTV pasien "TD : 110/80 " "
" " " " "N : 74x/ menit " "
" " " " "RR : 25x/ menit " "
" " " " "S : 37,6 " "
" " " " " " "
" " " " " " "
" " " " "DS : pasien " "
" " " " "mengatakan merasa " "
" " " " "haus tapi tidak " "
" " " " "ingin minum banyak " "
" " " "Mengkaji tanda-tanda Hidrasi"Do : - mukosa bibir" "
" " " " "pasien masih " "
" " " " "terlihat kering " "
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EVALUASI KEPERAWATAN GAWAT DARURAT
Nama klien : Tn S umur : 38 th No.RM : 085378
TGL : 14-08-2014
"NO "Diagnosa Keperawatan "Evaluasi "
"1 "Ketidakefektifan pola "S : pasien mengatakan masih merasa sedikit "
" "nafas b/d hiperventilasi"sesak nafas "
" "yang ditandai dengan RR "O : - Ku lemah "
" ": 27 x/ menit "terpasang nasal canule "
" " "O2 masuk 4 liter "
" " "suara nafas Whezzing "
" " "A : masalah tercapai sebagian "
" " "P : lanjutkan intervensi "
"2 " " "
" " "S : pasien mengatakan merasa haus namun "
" "kekurangan volume cairan"tidak ingin minum terlalu banyak "
" "b/d kehilangan cairan "O : - pasien terlihat lemas "
" "berlebih yang ditandai "TD : 110/80 "
" "dengan peningkatan suhu "RR : 25x/ menit "
" "tubuh 37.9 C "N : 74 x/ menit "
" " "S : 37.6 "
" " "A : masalah teratasi sebagian "
" " "P : lanjutkan intervensi "
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" "Data Subyektif & Obyektif"Interpretasi "Diagnosa "
"NO " " "Keperawatan "
"1 "Ds : pasien mengatakan "Penyempitan saluran "Ketidakefektifan "
" "merasa sesak nafas "nafas "pola nafas b/d "
" "Do : "peningkatan keb. "hiperventilasi "
" "Pasien terlihat gelisah "Suplai O 2 "yang ditandai "
" "RR : 27 x/ menit " "dengan RR : 27 x/"
" "Adanya pernafasan cuping "hiperventilasi "menit "
" "hidung " " "
" "suara nafas whezzing "pola nafas tidak " "
" " "efektif " "
" " " " "
" " " " "
"2 "Ds : pasien mengeluh " " "
" "muntah dan susah menelan "mual - muntah "kekurangan volume"
" "Do : - pasien terlihat " "cairan b/d "
" "gelisah "kehilangan cairan "kehilangan cairan"
" "suhu tubuh meningkat 37,9"berlebih "berlebih yang "
" "C " "ditandi dengan "
" "Pasien terlihat lemas "metabolisme terganggu "peningkatan suhu "
" "Suara nafas gargling " "tubuh 37.9 C "
" "R : 28x/menit "peningkatan suhu tubuh" "
" "mukosa bibir pasien " " "
" "kering "peningkatan kebutuhan " "
" "TD : 100/70 "cairan " "
" "N : 83 x/ menit " " "
" " "kekurangan volume " "
" " "cairan " "
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