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 : .........................................................
8.Keluhan utama :…………………………………….
9.Riwayat penyakit dahulu:……………………………………
B. PENGKAJIAN PRIMER:
1. Airway (jalan nafas)
..................................................................................................................................
..................................................................................................................................
2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, bantuan nafas, dll)
............................................................................................................................
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b. Palpasi (total fremitus, dll)
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c. Perkusi (pembesaran paru, dll)
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d. Auskultasi (suara nafas)
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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 :
ANALISA DATA

Hari/tangg Jam Data Fokus Masalah Etiologi

al

Diagnosa Keperawatan

1. ………………………………………………………………………………

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3. ………………………………………………………………………………
 Assessment
Tanggal/Jam Subjektif Objektif (Laboratorium Dan Plan Implementasi Evaluasi
Therapy)
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………………………. ………………………. ………………………… Kriteria Hasil (NOC): ……………………. O:………………….
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Intervensi (NIC): P:………………….
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