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FORMAT PENULISAN RESUME ASUHAN KEPERAWATAN PRAKTEK PROFESI

KEPERAWATAN GAWAT DARURAT PSIK FK UNUD

Nama Mahasiswa :

Nim :

Identitas Pasien

Nama :

Umur :

Jenis Kelamin :

Tanggal Masuk RS :

RIWAYAT

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SURVEY PRIMER dan RESUSITASI AIRWAY DAN KONTROL SERVIKAL

1. Keadaan Jalan Nafas

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2. Masalah Keperawatan

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3. Intervensi / Implementasi
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4. Evaluasi

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BREATHING

1. Fungsi Pernafasan

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2. Masalah Keperawatan

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3. Intervensi / Implementasi

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4. Evaluasi

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CIRCULATION

1. Keadaan Sirkulasi

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2. Masalah Keperawatan

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3. Intervensi / Implementasi

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4. Evaluasi

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DISABILITY

1. Penilaian Fungsi Neurologis

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2. Masalah Keperawatan

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3. Intervensi / Implementasi

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4. Evaluasi

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EKSPOSURE

1. Penilaian Fungsi Eksposure

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2. Masalah Keperawatan

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3. Intervensi / Implementasi

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4. Evaluasi

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PENGKAJIAN SEKUNDER/SURVEY SEKUNDER

1. FIVE INTERVENSION

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2. GIVE COMFORT (PQRSTUV)

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3. H (1) SAMPLE

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4. H (2) HEAD TO TOE

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5. INSPEKSI BACK / POSTERIOR SURFACE

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6. HASIL LABORATORIUM

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7. HASIL PEMERIKSAAN DIAGNOSTIK

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8. TERAPI DOKTER

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Masalah Keperawatan dari Pengkajian Sekunder

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Intervensi / Implementasi

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Evaluasi

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RESUME PERENCANAAN PASIEN PINDAH RUANGAN / PULANG

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