PENGKAJIAN KEPERAWATAN GAWAT DARURAT

PICU/NICU/ICU/ICCU RSUD ABDUL WAHAB SJAHRANIE SAMARINDA

I. Identitas Mahasiswa
Nama : ..................................................................................................................
NIM : ..................................................................................................................
II. Identitas Klien
Nama : ..................................................................................................................
Umur : ..................................................................................................................
No. MR : ..................................................................................................................
Jenis Kelamin : ..................................................................................................................
Tanggal : ..................................................................................................................
BB : ..................................................................................................................
Agama : ..................................................................................................................
Status : ..................................................................................................................
Pendidikan : ..................................................................................................................
Pekerjaan : ..................................................................................................................
Alamat Rumah : ..................................................................................................................
Diagnosa Medis : ..................................................................................................................

III. Keluhan Utama

A. Saat MRS (Tgl........................................ Pukul:………………………)
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B. Saat Pengkajian (Tgl………………………..Pukul : ……………………..)
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 C. Alasan dirawat
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IV. Primary Survey

A. Air Way : .....................................................................................................................
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B. Breathing :
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C. Circulation :
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D. Fluid : .....................................................................................................................
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V. Secondary Survey
A. Brain : .....................................................................................................................
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B. Breathing : .....................................................................................................................
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C. Blood : .....................................................................................................................
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D. Bladder : .....................................................................................................................
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E. Bowel : .....................................................................................................................
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F. Bone : .....................................................................................................................
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VI. Pemeriksaan Penunjang

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 VII. Analisa Data

No Data Etiologi Problem

VIII. Daftar Diagnosa Keperawatan Berdasarkan Prioritas
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 IX. Intervensi Keperawatan

Diagnosa Keperawatan
No NOC NIC
NANDA
 X. Implementasi Keperawatan

No Tgl/Jam Pkl Implementasi Respon Klien Paraf

 XI. Evaluasi

No Hari/Tgl PKL No. Dx Evaluasi Paraf