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  • Program Studi Ilmu Keperawatan Universitas Jember Format Pengkajian Keperawatan Gawat Darurat (Instalasi Gawat Darurat)

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    Dianarisqiya Wati
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    This document contains a template for nursing assessment in emergency situations (emergency room installation) in the Nursing Science Study Program at the University of Jember. The template includes sections for collecting the patient's identity, conducting a primary survey assessing the patient's response, airway, breathing, circulation, disability and exposure, and performing a secondary survey involving the patient's medical history, prior health history including allergies and current medications, and a head-to-toe assessment of vital signs and the condition of the patient's head, neck, chest, abdomen, genitals, and extremities.

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    Gawat darurat

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    This document contains a template for nursing assessment in emergency situations (emergency room installation) in the Nursing Science Study Program at the University of Jember. The template includes sections for collecting the patient's identity, conducting a primary survey assessing the patient's response, airway, breathing, circulation, disability and exposure, and performing a secondary survey involving the patient's medical history, prior health history including allergies and current medications, and a head-to-toe assessment of vital signs and the condition of the patient's head, neck, chest, abdomen, genitals, and extremities.

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    14 views7 pages

    Program Studi Ilmu Keperawatan Universitas Jember Format Pengkajian Keperawatan Gawat Darurat (Instalasi Gawat Darurat)

    Uploaded by

    Dianarisqiya Wati
    This document contains a template for nursing assessment in emergency situations (emergency room installation) in the Nursing Science Study Program at the University of Jember. The template includes sections for collecting the patient's identity, conducting a primary survey assessing the patient's response, airway, breathing, circulation, disability and exposure, and performing a secondary survey involving the patient's medical history, prior health history including allergies and current medications, and a head-to-toe assessment of vital signs and the condition of the patient's head, neck, chest, abdomen, genitals, and extremities.

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    of 7

    PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

    FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT


    (INSTALASI GAWAT DARURAT)

    Nama Mahasiswa :
    NIM :
    Tempat Pengkajian :
    Tanggal :

    I. Identitas Klien
    1. Nama :
    2. No RM :
    3. Tanggal lahir/ Umur :
    4. Alasan masuk RS:

    5. Diagnosa medis:

    II. Pengkajian
    A. Primary survey
    1. Respon
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    2. Airway
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    3. Breathing
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    4. Circulation
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    5. Disability
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    6. Exposure
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    B. Secondary survey
    1. Riwayat penyakit sekarang
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    2. Riwayat kesehatan terdahulu:

    a. Penyakit yang pernah dialami

    .…………………………………………………………………………………………….......

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    b. Alergi (obat, makanan, dll)

    .…………………………………………………………………………………………….......

    c. Obat-obat yang digunakan

    .…………………………………………………………………………………………….......

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    3. Pengkajian Head to toe

    Keadaan umum
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    Tanda vital & nyeri

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    a. Kepala

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    b. Leher
    .……………………………………………………................................................................

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    c. Dada
    .………………………………………………………………………………………...….
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    d. Abdomen

    .…………………………………………………………………………………………………

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    e. Urogenital
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    f. Ekstremitas
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    g. Punggung

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    h. Keadaan lokal .

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    7. Tindakan prehospital
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    8. Pemeriksaan penunjang
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    CATATAN PERKEMBANGAN

    WAKTU DATA ACTION RESPONSES

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