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    LAMPIRAN 4

    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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    LAMPIRAN 4

    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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    LAMPIRAN 4

    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

    000000000000000000000000000000000000

    PENGKAJIAN SEKUNDER 2 SURVE SEKUNDER

    '( RI000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((

    $( RKS

    000000000000000000000000000000000000((000000000000000000000000000000000000((000000000000000000000000000000000000((6( RKK

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    LAMPIRAN 4

    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 :

    JantungIns%eksi :Pal%asi :Perkusi :Auskultasi :

    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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    LAMPIRAN 4

    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(

    8" 000000000000000000000000000000(

    9" 000000000000000000000000000000(

    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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    LAMPIRAN 4

    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(