RESUME PENGKAJIAN KEPERAWATAN GAWAT DARURAT

I. Identitas Mahasiswa
Nama :.
NIM :
II. Identitas Klien
Nama : Agama :
Umur : Status :
No. MR : Pendidikan :
Jenis Kelamin : Pekerjaan :
Tanggal : Alamat Rumah :
BB : Diagnosa Medis :
III. DATA KHUSUS
Subjektif
a. Keluhan Utama :

b. SAMPLE
1) Symptom
2) Alergies
3) Medication
4) Penyakit yang diderita
5) Last meal (makan terakhir)
6) Event (kejadian sebelum cedera)
Objektif
a. Air Way
b. Breating
c. Circulation
d. Disability
e. Exposure & environment
f. Full set of vital sign, five intervention
g. Give comport (memberi kenyamanan)
h. History
 1. Head to toe assessment

2. Pemeriksaan penunjang

IV. ANALISA DATA

N
DATA ETIOLOGI PROBLEM
O
 V. Daftar Diagnosa Keperawatan berdasarkan prioritas
1...................................................................................................................................................
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2...................................................................................................................................................
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3...................................................................................................................................................
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VI. INTERVENSI KEPERAWATAN

Tgl/ No
Dx. Kep NOC NIC
jam Dx
 VII. IMPLEMENTASI KEPERAWATAN

N
TGL/J
O IMPLEMENTASI RESPON KLIEN
AM
DX

VIII. EVALUASI

DX.
TGL/JAM EVALUASI S.O.A.P PARAF
NO