NOMOR REGISTER

NOMOR RM

NAMA : ............................................................................

SEX : ..............UMUR ............RUANG/KELAS......................

Triase :
 NOMOR REGISTER

NOMOR RM

NAMA : ............................................................................

SEX : ..............UMUR ............RUANG/KELAS......................

DATA DIAGNOSA KEPERAWATAN

I. PENGKAJIAN PRIMER Bersihan jalan nafas tidak efektif

1. Airway
Sumbatan lendir/sputum warna .... darah lidah Pola nafas tidak efektif
benda asing spasme jalan nafas t.a.k
Gangguan pertukaran gas
2. Breathing
Penurunan curah jantung
t.a.k ronchi rales wheezing kusmaul stridor
chinestoke dyspnea tachipnea apnea sesak Gangguan perfusi jaringan perifer
saat/tdk aktifitas
Gangguan perfusi jaringan serebral
3. Circulation
t.a.k akral dingin/hangat nadi kuat/lemah perdarahan Nyeri
di .................. nyeri dada
Gangguan volume cairan : kurang
4. Disability dari kebutuhan
t.a.k kelumpuhan ektremitas atas/bawah nyeri tulang
Gangguan volume cairan : lebih dari
kebutuhan
II. PENGKAJIAN SEKUNDER
1. Riwayat Penyakit sekarang , Gangguan kebutuhan nutrisi sel :
Keluhan utama ,dan alasan masuk rumah sakit kurang dari kebutuhan
( uraikan ) ..........................................................................................
.................. Gangguan termoregulasi : hipertermi
...........................................................................................................
. Gangguan termoregulasi : hipotermi
...........................................................................................................
. Kecemasan
...........................................................................................................
Resiko tinggi cidera berulang
.
........................................................................................................... Keterbatasan aktifitas
.
........................................................................................................... Mual
.
...........................................................................................................
.
........................................................................................................... Diagnosa Medis :
.
...........................................................................................................
.
...........................................................................................................
.
...........................................................................................................
.
...........................................................................................................
.
2. Penyakit terdahulu
DM Hipertensi Asthma Jantung Paru
............ tahun ..............
3. Riwayat alergi
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Obat..................... makanan .......................

4. Riwayat keluarga
DM Hipertensi Asthma Jantung Hemofili
5. Pemeriksaan fisik
TD ...........mmHg, Suhu ......oC , Resp ........X/mnt,Nadi.......X/mnt
Kesadaran : CM Apatis Somnolent Soporus Coma
Skala Nyeri : ……………………..
Implementasi :
Kepala :
t.a.k hematoma ............. ..................
Leher :
t.a.k nyeri tekan .............. ..................
Dada :
t.a.k retraksi hematom jejas ...........
Perut :
t.a.k distensi kandung kemih nyeri tekan
acites tegang
Integumen : cyanosis v.ekskoriasi .......................
v.Laceratum............... edema di ...........
Ekstremitas : t.a.k hemiparese/plegi ........... tremor
Deformitas fraktur terbuka ..........................

6. Pemeriksaan penunjang
EKG CT scan ............. Rontgen ................. USG
pemrik. Lab ..........................................

7. Tindakan / Pengobatan
Infus ............... heacting .............
Reposisi ..................... Gips....................
Obat ...........................................................

Intervensi : Evaluasi :

Pembimbing Klinik Pembimbing Akademik Mahasiswa

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