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ASUHAN KEPERAWATAN PADA Tn/Ny/Nn/An.........

DENGAN......................................................
I.

II.

III.

Identitas Klien
Nama
Usia
Jenis Kelamin
Alamat
No. Registrasi
Diagnosa Medis
Tanggal MRS
Jam MRS
Tanggal Pengkajian
Jam Pengkajian

:
:
:
:
:
:
:
:
:
:

Data Subyektif
Kasus Trauma
KeluhanUtama

Mekanisme Trauma

SAMPLE
Sign and Symptom

Allergy

Medication

Past Medical History

Last Oral Intake

Event Preceding
Data Obyektif
Kasus Trauma
Airway

Breathing

Circulation

Disability

Exposure

Full Vital Sign

Head to Toe
KeadaanUmum

Kepala, Leher dan Wajah


- Dada

- Respirasi
Cardiovaskuler

Abdomen

Pelvis dan Genetalia

Ekstremitas

Punggung (Manuver Log Roll)

IV.

Pemeriksaan Penunjang
ECG

Ro. Toraks

BGA
Pa CO2 :
Pa O2 :
Sa O2 :
pH
:
HCO3 :

V.

Therapi

VI.

Tindakan Resusitasi
N
o
1
2
3
4
5
6
7

Tgl/Jam

Tindakan Resusitasi

Keterangan

VII.

Analisa Data
No

Tanda

Etiologi

Problem

VIII.

Prioritas Diagnosa Keperawatan


No

Prioritas Diagnosa Keperawatan

IX.

Intervensi Keperawatan

X.
XII.
Tg
Dx.
l/Jam
XI.
Kep
XVI.
XXXIV.
1
XVII.
XVIII.
XIX.
XX.
XXI.
XXII.
XXIII.
XXIV.
XXV.
XXVI.
XXVII.
XXVIII.
XXIX.
XXX.
XXXI.
XXXII.
XXXIII.
XXXVIII. LII.
2
XXXIX.
XL.
XLI.
XLII.
XLIII.
XLIV.
XLV.
XLVI.

XIII.

Tujuan

XIV.

Intervensi Keperawatan

XV.
td

XXXV.

XXXVI.

XXXVII.

LIII.

LIV.

LV.

XLVII.
XLVIII.
XLIX.
L.
LI.
LVI.
LXXIV.
3
LVII.
LVIII.
LIX.
LX.
LXI.
LXII.
LXIII.
LXIV.
LXV.
LXVI.
LXVII.
LXVIII.
LXIX.
LXX.
LXXI.
LXXII.
LXXIII.
LXXVIII.
LXXIX.

LXXV.

LXXVI.

LXXVII.

LXXX. Implementasi
LXXXI.LXXXIII.
Dx.
Tgl/Jam
LXXXII.
Kep
LXXXVII.CL.
LXXXVIII.
LXXXIX.
XC.
XCI.
XCII.
XCIII.
XCIV.
XCV.
XCVI.
XCVII.
XCVIII.
XCIX.
C.
CI.
CII.
CIII.
CIV.
CV.
CVI.
CVII.
CVIII.
CIX.
CX.
CXI.
CXII.
CXIII.
CXIV.
CXV.

LXXXIV.

CLI.

Implementasi

LXXXV.

CLII.

Respon Pasien

LXXXVI.
TTD

CLIII.
CLVIII.
CLXIII.
CLXVIII.
CLXXIII.

CXVI.
CXVII.
CXVIII.
CXIX.
CXX.
CXXI.
CXXII.
CXXIII.
CXXIV.
CXXV.
CXXVI.
CXXVII.
CXXVIII.
CXXIX.
CXXX.
CXXXI.
CXXXII.
CXXXIII.
CXXXIV.
CXXXV.
CXXXVI.
CXXXVII.
CXXXVIII.
CXXXIX.
CXL.
CXLI.
CXLII.
CXLIII.
CXLIV.
CXLV.
CXLVI.
CXLVII.
CXLVIII.
CXLIX.

CLXXIV.
Discharge Palning
CLXXV.
Format Discharge Planning (Pulang/Pindah Ruangan)
CLXXVI.
CLXXVIII.
S
CLXXVII.
CLXXIX.
CLXXXVIII.
O
CLXXX.
CLXXXI.
CLXXXII.
CLXXXIII.
CLXXXIV.
CLXXXV.
CLXXXVI.
CLXXXVII.
CLXXXIX.
CXCI.
CXCII.
A
CXC. CXCIII.
CXCIV.
CXCV. CXCVII.
CXCVIII.
P
CXCVI.CXCIX.
CC.
CCI.
CCII. CCIX.
I
CCIII.
CCIV.
CCV.
CCVI.
CCVII.
CCVIII.
CCX. CCXV.
E
CCXI.
CCXII.
CCXIII.
CCXIV.
CCXVI.
CCXVII.
Nama pasien: Tn/Ny/Nn/An_______________(P/L) masuk rumah sakit
pada tanggal_____________ jam______WIB dengan diagnosa
medis_________________ telah diberikan tindakan diatas. Untuk itu perlu perawatan
lanjutan di____________ kunjungan rutin ke___mulai tanggal____________
CCXVIII.
CCXIX.
Terapi obat yang diberikan :
CCXX.
CCXXI.
Anjuran
CCXXII.
CCXXIII.
CCXXIV.
Malang,_____________________
CCXXV.
Ttd
CCXXVI.

CCXXVIII.

CCXXVII.
(____________________)