ASUHAN KEPERAWATAN PADA Tn/Ny/Nn/An……...

DENGAN ………………………………………….

I. Identitas Pasien
Nama : …………………………………………………………………..
Usia : …………………………………………………………………..
Jenis kelamin : …………………………………………………………………..
Alamat : …………………………………………………………………..
No. Reg : …………………………………………………………………..
Diagnosa medis : ……………………………………………………………………
Tanggal MRS : ……………………………………………………………………
Jam MRS : ……………………………………………………………………
Tanggal pengkajian : …………………………………………………………………..
Jam pengkajian : …………………………………………………………………..

II. Data Subyektif

 Keluhan utama
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 Provocative
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 Quality
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 Regio/Radiation
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 Severe-severity
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  Skala
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 Time
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 Mekanisme kejadian/ MIVT (mechanism of injury, injury sustained, vital signs,
treatments)
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A ……………………………………………………………………………………………………
M ……………………………………………………………………………………………………
P ……………………………………………………………………………………………………
L ……………………………………………………………………………………………………
E ……………………………………………………………………………………………………

 Riwayat penyakit dahulu

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III. Data Obyektif
 Airway
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 Breathing
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 Circulation
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FORM ASKEP EMERGENCY TRAUMA 2

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 Disability
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 Exposure
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 Full Vital Signs – Five intervention – Family presence
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 Give Comfort measures
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 Head to Toe Examination

 Keadaan Umum
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 Kepala dan Wajah
- Kepala
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- Mata
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- Telinga
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- Hidung
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- Mulut
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- Leher
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FORM ASKEP EMERGENCY TRAUMA 3

  Dada
Jantung :

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Paru :
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 Perut dan Pinggang

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 Pelvis dan Perineum
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 Ekstremitas
Atas
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Bawah
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 Inspect posterior surface
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IV. Pemeriksaan Penunjang

FORM ASKEP EMERGENCY TRAUMA 4

  Lab darah :
 Lab urin :
 ECG :
 Rontgen :
 USG :
 CT Scan :
 BGA :
 Pa CO2 : ……………………………………………………….
 Pa O2 : ……………………………………………………….
 Sa O2 : ……………………………………………………….
 pH : ……………………………………………………….
 HCO3 : ……………………………………………………….

V. Therapi :
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FORM ASKEP EMERGENCY TRAUMA 5

Tindakan Resusitasi
No Tgl/Jam Tindakan Resusitasi Keterangan

FORM ASKEP EMERGENCY TRAUMA 6