Nama Mahasiswa :

NIM :
Rumah Sakit :
Prodi Profesi Ners STIKes Hafshawaty Pesantren Zainul Hasan
Ganggong-Probolinggo

FORMAT RESUME ASUHAN KEPERAWATAN

GAWAT DARURAT TRAUMA

I. IDENTITAS
Nama : ..................................................................................................
Umur : ..................................................................................................
Agama : ..................................................................................................
Alamat : ..................................................................................................
Pendidikan : ..................................................................................................
Pekerjaan : ..................................................................................................
Tanggal MRS : ..................................................................................................
Diagnosa Medis : ..................................................................................................
No. Register : ..................................................................................................
Tanggal Pengkajian : ..................................................................................................

II. DATA SUBYEKTIF

a Keluhan Utama Saat Pengkajian
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b Riwayat Penyakit Sekarang
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c Riwayat Penyakit Dahulu

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d Riwayat Alergi
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e Pengobatan Yang Digunakan Selama Ini
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f Makan Terakhir
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III. DATA OBYEKTIF

Keadaan Umum : ......................................................................................
TTV :
TD : RR : SpO2 :
HR : Suhu :
a Airway
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b Breathing
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c Circulation
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d Disability
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e Exposure
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f Full Vital Sign
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g Give Comfort
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h Head To Toe
1. Keadaan Umum : ......................................................................................
2. TTV :
TD : RR : SpO2 :
HR : Suhu :
 3. Nyeri : P : ..................................................................................................
Q : ..................................................................................................
R : ..................................................................................................
S : ..................................................................................................
T : ..................................................................................................
4. Resiko Jatuh
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5. Pemeriksaan Fisik (Fokus)

i Inspeksi Back/Posterior
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IV. ANALISA DATA

No DATA ETIOLOGI MASALAH KEP

V. PEMERIKSAAN PENUNJANG

VI. EVALUASI
VII. PENATALAKSANAAN

VIII. DISCHARGE PLANNING

.......................................2020
Pembimbing Ruangan Mahasiswa

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