format kgd stikes buleleng
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FORMAT PENGKAJIANKEPERAWATAN GAWAT DARURAT
Nama Mahasiswa :NIM :
Identitas Pasien :Nama :Umur :Jenis Kelamin :Pekerjaan :Agama :Tanggal Masuk RS :Alasan Masuk : :
Initial survey:
A alertness! :
" #er$al! :
P %ain! :
U unser%&ns! :
SURVE PRIMER !an RESUSITASI
a" AIRWA DAN KONTRO# SERVIKA#
'( Keadaan jalan na)as
Perna)asan :U%a*a $erna)as :+enda asing di jalan na)as :
+un*i na)as :
,em$usan na)as :
-( Masalah.diagn&sa Ke%erawatan$ersi%an &alan na'as ta( e'e(ti'
/( Inter#ensi . Im%lementasiMana&e)en &alan na'as *air+ay )ana,e)ent-000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
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4( 1#aluasi000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
$" $REAT.ING'( 2ungsi %erna)asan
Jenis Perna)asan : Taki%neu2rekwensi Perna)asan :Retraksi 3t&t $antu na)as :Kelainan dinding th&raks : simetris %erlukaan jejas trauma!000000000000000000000000000000000000000000000000000000000000000000+un*i na)as :,em$usan na)as :
-( Masalah.diagn&sa Ke%erawatanP&la na)as tak e)ekti)5gn %ertukaran gas000000000000000000000000000000000000000000000000000000000000000000000000
/( Inter#ensi . Im%lementasiTera%i &ksigen000000000000000000000000000000000000
000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
4( 1#aluasi000000000000000000000000000000000000000000000000000000000000000000000000
/" 0IR0U#ATION'( Keadaan sirkulasi
Perdarahan internal.eksternal! :Ka%ilari Re)ill :Nadi radial.6ar&tisAkral %eri)erN*eri7airan
-( Masalah.diagn&sa Ke%erawatan73 menurun.risik&Risik& s*&k
N*eri akut5gn keseim$angan 6airan dan elektr&lit7airan le$ih.kurangRisik& %er)usi m*&kard tak e)ekti)
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Risik& %er)usi jaringan %eri)er tak e)ektikRisik& taksta$il gluk&sa darah000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
/( Inter#ensi . Im%lementasi00sesuai masalah0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
4( 1#aluasi000000000000000000000000000000000000000000000000000000000000000000000000
1" DISA$I#IT'( Pemeriksaan Neur&l&gis:
57S : 10("0M0(( : 00((Re)le8 )isi&l&gis :Re)le8 %at&l&gis :
9( Masalah.diagn&sa Ke%erawatanRisik& %er)usi sere$ral tak e)ekti)000000000000000000000000000000000000
000000000000000000000000000000000000000000000000000000000000000000000000
( Inter#ensi . Im%lementasiPeningkatan %er)usi sere$ral000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
;( 1#aluasi000000000000000000000000000000000000
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PENGKAJIAN SEKUNDER 2 SURVE SEKUNDER
'( RI000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((
$( RKS
000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((6( RKK
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000000000000000000000000000000000000((000000000000000000000000000000000000((
-( RIAN M1KANISM1 TRAUMA
000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((
/( P1M1RIKSAAN 2ISIK ,1A> T3 T31!
a( Ke%alaKulit ke%ala :Mata :Telinga :,idung :Mulut dan gigi :ada. th&raksParu?%aru :Ins%eksi :Pal%asi :
Perkusi :Auskultasi :
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d( A$d&men
Ins%eksi :Pal%asi :Perkusi :Auskultasi :
e( Pel#isIns%eksi :Pal%asi :
)( Perineum dan rektum :
g( 5enitalia :
h( 1kstremitasStatus sirkulasi :
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Keadaan injur* :
i( Neur&l&gis :2ungsi sens&rik :
2ungsi m&t&rik :
4( ,ASIL LA+3RAT3RIUM
000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((
9( ,ASIL P1M1RIKSAAN >IA5N3STIK
000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((
( T1RAPI >3KT1R000000000000000000000000000000000000((000000000000000000000000000000000000((
$" ANA#ISIS DATA
Data '31us Analisis Masala%
>ata Su$*ekti) :
>ata 3$*ekti) :
Analisis !en,an43%3n )asala%
0" DIAGNOSA KEPERAWATAN DAN PRIORITAS MASA#A.
5" 000000000000000000000000000000((
6" ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
7" 000000000000000000000000000000(
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D" PEREN0ANAAN
N3D
Tu&uan Intervensi Rasi3nal
S M A R T : tulisNO0 yan, sesuai!isertai !en,an
Tulis :NI0 :Nursin, a1tivities :
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in!i1at3r 1a4aian
E" PE#AKSANAAN
N3 T,l2 &a) I)4le)entasi Res43n Para'
F" EVA#UASI
N3 T,l 2 &a) 0atatan Per(e)/an,an Para'
S : data su$*ekti)3 : data &$*ekti)A : analisis a%akah tujuan ter6a%ai atau tidak denganhasil : ter6a%ai semua indi6at&r ter6a%ai! se$agiansatu atau le$ih indi6at&r ter6a%ai! dan tidak ter6a%aisemua indi6at&r tidak ter6a%ai!P : dianalisis semua as%ek asuhan diagn&seke%erawatan im%lementasi inter#ensi N37 danwaktu!%eren6anaan dilanjutkan atau dim&di)ikasi( +ila tujuan$elum ter6a%ai mungkin %erlu dilakukan m&di)ikasi%eren6anaan menga6u %ada hasil
RESUME DAN PEREN0ANAAN PASIEN PU#ANG000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((
000000000000000000000000000000000000((
00000(@ 0000-'Nama Pem$im$ing . 7I: Nama Mahasiswa
000000000(( 0000000000(((NIP NIM
Nama Pem$im$ing . 7T
0000000000(NIP(