P

A
G
E

JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN TRAUMA

Nama Mahasiswa

Tempat Praktik

NIM

Tgl. Praktik

1. Identitas Klien
Nama

: .......................................... No. RM

: ........................................

Usia

: ............. tahun

: ........................................

Jenis kelamin

: .......................................... Tgl. Pengkajian

Alamat

: .......................................... Sumber informasi : ........................................

Status pernikahan

: .......................................... Agama

: ........................................

Suku

: .......................................... Pendidikan

: ........................................

Pekerjaan

: ..........................................

Tgl. Masuk

: ........................................

2. Data Subyektif
1. Keluhan utama MRS

: ...............................................................................................................

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
2. Mekanisme Kejadian

: .................................................................................................

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................

3. SAMPLE
Sign & Symptom
.....................................................................................................................................................

P
A
G
E

..................................................................................................................................................... 8
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Allergies
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Medication
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Past medical history
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Last meal
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Event before accident

.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

P
A
..................................................................................................................................................... G
E

Diagnosa Medis

.....................................................................................................................................................

..................................................................................................................................................... 8
.....................................................................................................................................................

3. Data Obyektif
Airway
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Breathing
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Circulation
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Disability
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Exposure / Environment
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Full set of vital sign

Tekanan darah : mmHg
Suhu

:oC

Nadi

:... x/menit

RR

: x/menit

P
A
G
E
8

Five Intervention
Monitor Irama dan rate jantung : ..................................................................................................
.....................................................................................................................................................
Pasang pulse oximetri : ................................................................................................................
.....................................................................................................................................................
Pasang kateter urine : ..................................................................................................................
.....................................................................................................................................................
Pasang NGT : ..............................................................................................................................
.....................................................................................................................................................
Pemeriksaan Lab : .......................................................................................................................
.....................................................................................................................................................

Give Comfort
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Head to toe examination

1. Kepala & Leher
a. Kepala:
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Mata:
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

c. Hidung:

P
A
.....................................................................................................................................
G
E

.....................................................................................................................................
8
.....................................................................................................................................

.....................................................................................................................................
d. Mulut & tenggorokan:
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
e. Telinga:
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
f. Leher:
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
2. Thorak & Dada:
- Inspeksi: .................................................................................................................................
...............................................................................................................................................
- Palpasi: ..................................................................................................................................
...............................................................................................................................................
- Perkusi: ..................................................................................................................................
...............................................................................................................................................
- Auskultasi:..............................................................................................................................
...............................................................................................................................................
.................................................................................................................................................
3. Punggung & Tulang Belakang
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

P
A
Inspeksi: .......................................................................................................................................
G
E

4. Abdomen
b.

......................................................................................................................................................
8
......................................................................................................................................................

c.

Palpasi:.........................................................................................................................................
.....................................................................................................................................................
...................................................................................................................................................

d.

Perkusi: ........................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

e.

Auskultasi: ....................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

5. Genetalia
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
6. Ekstremiitas
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
7. Kulit & Kuku
a. Kulit:
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
b. Kuku:
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

P
A
............................................................................................................................................................
G
E

4. Hasil Pemeriksaan Penunjang

............................................................................................................................................................
8
............................................................................................................................................................

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................

5. Terapi
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................