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Format resume+IGD
Format resume+IGD
Nim : 111.420.0678
Prodi : Sarjana Keperawatan
Institusi : Stikes Darul Azhar Batulicin
Nama Pasien :
Tanggal MRS :
Diagnosa Medis :
Perawatan lanjutan :
Kunjungan rutin ke :
Terapi Obat yang diberikan :
Anjuran :
S : SUBYEKTIF
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O : OBYEKTIF
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A : ANALISA DATA, DIAGNOSA KEPERAWATAN
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P : PLANNING (NCP)
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I : INTERVENSI
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E : EVALUASI
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FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT PADA ORANG DEWASA
No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...
IDENTITAS
TRIAGE P1 P2 P3 P4
GENERAL IMPRESSION
Keluhan Utama :
Mekanisme Cedera :
Orientasi (Tempat, Waktu, dan Orang) : Baik Tidak Baik, ... ... ...
Diagnosa Keperawatan:
AIRWAY
Inefektif airway b/d … … …
Jalan Nafas : Paten Tidak Paten Kriteria Hasil : … … …
PRIMER SURVEY
Diagnosa Keperawatan:
1. Inefektif pola nafas b/d … … …
BREATHING 2. Kerusakan pertukaran gas b/d … …
…
Diagnosa Keperawatan:
1. Kerusakan integritas jaringan b/d …
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EXPOSURE
2. Kerusakan mobilitas fisik b/d … … …
3. … … …
Diagnosa Keperawatan:
SECONDA
Medikasi :
Even/Peristiwa Penyebab:
Tanda Vital :
BP : N: S: RR :
PEMERIKSAAN FISIK Diagnosa Keperawatan:
1. … … …
RY SURVEY
2. … … …
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