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DOKUMENTASI

ASUHAN KEPERAWATAN DI RUANG IGD

Tanggal pengkajian : ...................................................

Pukul : ............................................

A. PENGKAJIAN
1. Identitas Pasien
Nama

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

Umur

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

Jenis kelamin : .........................


Alamat/No.telp : ...............................................................................................................................
Pekerjaan

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

Agama

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

No. Register

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

2. Keluhan Utama
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3. Riwayat Alergi
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4. Riwayat Pengobatan Terakhir/Obat yang Telah atau Sedang Dikonsumsi
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5. Riwayat Penyakit Dahulu
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6. Riwayat Makanan yang Dikonsumsi Terakhir
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7. Kondisi Lingkungan yang Berhubungan dengan Kejadian Trauma
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8. Primary Survey
a. Airway (jalan nafas)
Look

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

Listen

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

Feel

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

b. Breathing (pernafasan)
Look

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

Frekuensi : ...............................................................................................................................
Sianosis

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

c. Circulation (sirkulasi)
Nadi arteri carotis

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

Nadi arteri radialis

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

Frekuensi nadi

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

Akral (hangat/dingin)

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

Perdarahan

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

.......................................................................................................
.......................................................................................................
d. Disabality (tingkat kesadaran)
Respon verbal

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

Respon nyeri

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

e. Eksposure (paparan)
Kepala belakang

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

Punggung

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

Panggul

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

Kaki

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

9. Secundary Survey
Kepala

: .......................................................................................................................................
.......................................................................................................................................
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Leher

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

Bahu

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

Dada

: .......................................................................................................................................
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Perut

: .......................................................................................................................................
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Genetalia : .......................................................................................................................................
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Punggung : .......................................................................................................................................
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Panggul

: .......................................................................................................................................
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Tangan

: .......................................................................................................................................
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Kaki

: .......................................................................................................................................
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B. DIAGNOSA KEPERAWATAN
1

C. PERENCANAAN dan IMPLEMENTASI


Tentukan prioritas (P1, P2, P3, P4)
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

No

Tgl

Jam

Tindakan

Evaluasi setelah tindakan

No

Tgl

Jam

Tindakan

Evaluasi setelah tindakan

D. EVALUASI

Airway
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Breathing
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Circulation
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Disability
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Eksposure
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Malang,

April 2014

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