PROGRAM STUDI D-III KEPERAWATAN

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH MAGELANG
Kampus II Jln. Mayjend Bambang Soegeng Mertoyudan Magelang 56172
Telp (0293) 326945 web: www.ummgl.ac.id
email:tatausahafikes@gmail.com

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT (RESUME)

Nama Mahasiswa :.........................................................................................................

Semester/Tingkat :.........................................................................................................
Tempat Praktek :.........................................................................................................
Tanggal Pengkajian :.........................................................................................................

DATA KLIEN

A. DATA UMUM
1. Nama inisial klien : .........................................................
2. Umur : .........................................................
3. Alamat : .........................................................
4. Agama : .........................................................
5. Tanggal masuk RS/RB : .........................................................
6. Nomor Rekam Medis : .........................................................
7. Bangsal : .........................................................

B. PENGKAJIAN PRIMER:
1. Airway (jalan nafas)
.................................................................................................................................. ..............
....................................................................................................................
2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, bantuan nafas, dll)
............................................................................................................................
............................................................................................................................
b. Palpasi (total fremitus, dll)
............................................................................................................................
............................................................................................................................
c. Perkusi (pembesaran paru, dll)
............................................................................................................................
............................................................................................................................
d. Auskultasi (suara nafas)
............................................................................................................................
............................................................................................................................
3. Circulation
a. Vital sign:
1) Tekanan darah :
2) Nadi :
3) Suhu :
4) Respirasi :
b. Capilarry refill :
c. Akral :

4. Disability
a. GCS
E: ..... M: ........ V: ......
b. Pupil :
c. Gangguan motorik :
d. Gangguan sensorik :
 Assessment
Tanggal/Jam Subjektif Objektif (Laboratorium Dan Plan Implementasi Evaluasi
Therapy)
. . Tujuan: . S:.
. . ... . .
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. . Kriteria Hasil (NOC): . O:.
. . ... . .
. . ... . .
. . ... . .
... A:.
... .
... .
... .
Intervensi (NIC): P:.
... .
... .
... .
...
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