Anda di halaman 1dari 3

INITIAL ASSESMENT

PENILAIAN AWAL PASIEN IGD PUSKESMAS MUARA WAHAU II

Tanggal Masuk / Jam :


Tanggal Keluar/ Jam : No. Register IGD :
Nama Pasien : Jenis Kelamin :
Umur : Dokter :
Alamat :

Keadaan Umum

Kesadaran : GCS : E.......V......M......


Pupil :...........................
Keluhan Utama :
PRIMERY SURVEY ( PS TRAUMA )

Pemeriksaan Jalan Nafas ( AIRWAY ) :..................................................................................


 Gurgling ( Kumur-kumur ) Tindakan
:.............................................
 Snoring ( Ngorok ) Tindakan
:.............................................
 Stridor ( cidera inhalasi ) Tindakan
:.............................................
 Tidak ada kelainan
Pemeriksaan Servikal dan Tulang Basis Crani :..........................................................
 FR. CERVIKAL
 Trauma Kapitis dengan Penurunan kesadaran
 Multi Trauma
 Terdapat jejas diatas Clavicula kearah kepala
 Biomekanika Trauma yang mendukung
 FR. Tulang BASIS CRANI ( Ceder kepala )
 Perdarahan dari lubang hidung/telinga
 Racon Eyes ( Biru disekitar mata )
 Beatle sign ( Biru disekitar telinga )

Pemeriksaan pola Pernafasan ( Breathing ) :.......................................................................

 Inspeksi :.....................................................................................................................
.....................................................................................................................
 Auskultasi :.....................................................................................................................
.....................................................................................................................
 Palpasi :.....................................................................................................................
.....................................................................................................................
 Perkusi :.....................................................................................................................
......................................................................................................................
SECONDARY SURVEY
Anamnese
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................................................................................................
............................................................................................................................................................................................
 Alergi obat : Ada/Tidak Ada ( obat :.............................................................................................)
 Obat-obatan :....................................................................................................................jam :.................
 Riwayat Penyakit :.............................................................................................................................................
 Makanan Terakhir :...................................................................................................................jam :................

VITAL SIGN : TD N :...............x/mnt RR :............x/mnt T :..................C


:.......................mmHg
Pemeriksaan Head to toe ( BTLS : bentuk,tumor,luka,sakit )

..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
. ..................................................................................................................................
..................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Depan Belakang
Tindakan dan Therapi
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................................................................................................
....................
Ringkasan kondisi pasien sebelum meninggalkan pelayanan unit gawat darurat dan rencana tindak lanjut.
........................................................................................................................................................................................................
........................................................................................................................................................................................................
..............................................................................................................................
............................................................................................................... Pemeriksa,
...............................................................................................................

CATATAN PELAKSANAAN TINDAKAN


NO TGL/JAM TINDAKAN EVALUASI PARAF