A. Assessment
1. Patient Identity
3. Main Complaint
4. Primary Assessment
a. Airway
inviting the patient to talk to make sure whether or not the airway
obstruction is present. A patient who can speak clearly then the patient's
conditions.
With spinal control. Opening the airway using the 'head tilt chin lift'
technique or raising your head and raising your chin, check whether
there is a foreign object that can cause a closed airway. Vomit, food,
b. Breathing
artificial ventilation
breath or not. Next check the respiration status of the victim (speed,
c. Circulation
breath and inadequate, then breathing aid can be done. If there are no
d. Disability
Review the level of awareness of patients using GCS and pupil checks.
e. Exposure
Uninstall the patient's clothes and check the injury to the patient. If
examination. After all checks have been completed, cover the patient
with a warm blanket and keep the patient privacy, unless re-
f. Foley catheter
Attach the catheter to determine the urine output and check for the
medication in patients.
hypertension
b. Physical examination
Inspect and palpate the entire head and face for pigmentation, lacerations,
protection
2) Chest
a) Inspection: Front, side and rear chest wall inspection for blunt / blunt
3) Abdomen
bruises, and bullet exits. Also need to be studied anterior abdomen, back,
pelvis, and rectum. As for knowing the possibility of bleeding, the nurse
must use the cullen's sign guidance that is bleeding on umbilicus in case of
abdominal cavity).
distended.
Apply gentle pressure on each iliac crest with small motion movements;
patients pelvic fracture will lose sense (this maneuver will also cause pain
5) Extremities
begins in the proximal segment of each ekstermitas and palpation in the distal.
of the distal pulse and cel capillary refill on the tip of the nail. Assess skin
color on ekstermitas.
6) Back
Checking the back is done by log roll, tilting the patient while maintaining the
body's inheritance). At this time can be done back examination. Check for
edema and pain, as well as on the vertebral column check for deformity.
7) Neurological
level, pupil size and reaction, motor and sensory examination. The alteration in
c.Supporting investigation
3) Uretrography
4) Cystography
7) Photo Toraks
B. Nursing Diagnosis
circulatory changes, high blood sugar levels, invasive procedures and skin