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Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

FORMAT LAPORAN ANALISA SINTESA


RUANG GAWAT DARURAT

Nama Mahasiswa : ....................................... No.BP : ....................................


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Nama Pasien : ....................................... Umur : .................................
Diagnosa Medis : ....................................... Tanggal : .................................

1. Pengkajian Primer (Airway, Breathing, Circulation, Disability, Exposure/EKG)


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2. Diagnosa Keperawatan (Berdasarkan pengkajian primer, mengikuti pola PES)
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Azi Serandi,S.Kep

Bp. 1841312014
Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

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3. Tujuan dan Kriteria Hasil untuk masalah di atas
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4. Intervensi dan Implementasi Keperawatan (Untuk mengatasi masalah dari hasil
pengkajian primer)
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Azi Serandi,S.Kep

Bp. 1841312014
Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

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5. Evaluasi Hasil
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6. Pengkajian Sekunder (Meliputi pengkajian riwayat kesehatan & pengkajian head to
toe)
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Azi Serandi,S.Kep

Bp. 1841312014
Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

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7. Pemeriksaan Penunjang (Pemeriksaan laboratorium, X-ray, EKG, CT Scan, Dll)
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8. Diagnosa Keperawatan (Berdasarkan hasil pengkajian sekunder dan pemeriksaan
penunjang, mengikuti pola PES, minimal 2 diagnosa)
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Azi Serandi,S.Kep

Bp. 1841312014
Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

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9. Tujuan dan Kriteria Hasil untuk Diagnosa Keperawatan Sekunder
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10. Intervensi dan Implementasi Keperawatan prinsipal (Untuk 2 Diagnosa)
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Azi Serandi,S.Kep

Bp. 1841312014
Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

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11.Monitoring Klien (Monitor/pengkajian berkelanjutan yang dilakukan dan hasil yang
didapat)
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12. Evaluasi Hasil Akhir (Hasil yang didapat saat akhir perawatan)
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Azi Serandi,S.Kep

Bp. 1841312014
Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

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13. Evaluasi Diri
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14. Web of Caution (WOC)

Azi Serandi,S.Kep

Bp. 1841312014
Praktek Profesi Keperawatan Gawat Darurat

Fakultas Keperawatan UNAND 2018

Azi Serandi,S.Kep

Bp. 1841312014

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