PENGKAJIAN KEPERAWATAN KEGAWATDARURATAN DEPARTEMEN GAWAT DARURATSTIKES HANG TUAH SURABAYA

Nama:No. Rekam Medik

Jenis Kelamin: Pria WanitaTanggal Lahir: ..... /..../....Umur ....... Tahun

A. PRE HOSPITALWaktu Kedatangan :Transportasi :Kondisi datang :

Tindakan Pre Hospital

CPR O2 Infus Bidai Bebat Urin Kateter

Lain lain ............................................................................................................................................................................................................................................................................................................................

B. INTRA HOSPITALTRIAGE

Tanggal : ................................................Jam: .......................................................Perawat Triage: ...............................................

Alert VerbalKategori TriageKlasifikasi Kasus

Pain Unresponsive P1 P2 P3 Trauma Non Trauma

Keluhan Utama

Tanda dan gejala :..........................................................................................................................................................................................................................Karakteristik :..................................................................................................................................................................................................................................................

Onset :..........................................................................................................................................................................................................................Faktor yang meringankan :..................................................................................................................................................................................................................................................

Lokasi :..........................................................................................................................................................................................................................Tindakan yang telah dilakukan:...................................................................................................................................................................................................................................................

Durasi :..........................................................................................................................................................................................................................Faktor Penyebab :....................................................................................................................................................................................................................................................................................................................................

Riwayat Penyakit Dahulu: Diabetes Melitus Penyakit Jantung Hipertensi

CVA Asma

Lain-lain........................................................................................

Alergi: Ada TidakJelaskan : ...........................................................................................

GCS :E...........V...........M..........Total: .........Tensi : ......../........ mmHg

HR : ........x/menitRR : ....... x/menitSuhu : Aksila............... oC Rektal..............oC

AIRWAYCIRCULATION

Paten ObstruksiIrama Jantung : Reguler Irreguler

Tindakan : .......................................................................................................................................................................................................................................Akral : HKM DinginBasah

Kulit : Sianosis Jaundice Pucat

Normal

BREATHINGCRT : < 2 detik > 2 Detik

Pergerakan Dada : Simetris AsimetrisTurgor Kulit : Baik Sedang Jelek

Irama Pernapasan Reguler IrregulerEdema: Tidak ada adaLokasi :

Suara napas tambahan :Perdarahan : Tidak ada Ada

Tidak ada Ronchi CracklesJenis : ..........................................................................................................

Rales Stridor Wheezing

DISABILITYPEMERIKSAAN HEAD TO TOE.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Fraktur : Tidak ada ada

Lokasi : ...............................................................

Tipe : ..............................................................

Paralisis : Tidak ada ada

Lokasi :................................................................

Diagram Tubuh

C. PEMERIKSAAN DIAGNOSTIKJenis Pemeriksaan :HASIL

Darah Lengkap Kimia Klinik Gula Darah Acak.....................................................

Blood Gas Analisa Kultur Urin EKG.....................................................

BUN Kreatinin Foto Thorak.....................................................

Lain-Lain........................................................................................................................................

Tindak Lanjut KRS MRSPP DOA Operasi Pindah Lain-lain

D. PEMBERIAN TERAPIJamTindakan / MedikalKeterangan