FORMAT LAPORAN

ANALISA SINTESA TINDAKAN KEPERAWATAN

DI UNIT GAWAT DARURAT

Nama Mahasiswa
Tanggal
Initial Pasien
Usia
Diagnosa Medis

1. Pengkajian Primer
- Airway

:
:
:
:
:

Breathing

Circulation

Disability

Exposure

Folley Catheter

Gastric Tube

Heart monitor

2. Tindakan Keperawatan yang Dilakukan

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3. Evaluasi Hasil Tindakan

Subjektif
:
Praktikum Komprehensif_ Stase KGD PSIK
Universitas Tanjungpura Pontianak

Objektif

Analisa

Planning

4. Diagnosa Keperawatan
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5. Pengkajian Sekunder
A. Riwayat Penyakit
Alergi

Medikasi

Post Illnes

Last Meal

Event/Environtment :
B. Pemeriksaan Fisik Head to Toe
6. Pemeriksaan Penunjang
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7. Diagnosa Keperawatan ( 2 Diagnosa Utama )

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Praktikum Komprehensif_ Stase KGD PSIK
Universitas Tanjungpura Pontianak

8. Prinsip-Prinsip Tindakan ( Mandiri dan Kolaborasi serta Rasional Tindakan )

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9. Monitor Klien
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10. Evaluasi Diri

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Praktikum Komprehensif_ Stase KGD PSIK

Universitas Tanjungpura Pontianak