LAPORAN ASUHAN KEPERAWATAN GAWAT DARURAT

PRAKTEK KLINIK KEPERAWATAN GAWAT DARURAT

A. PENGKAJIAN KEPERAWATAN
Nama : HARI :
NIM : Tanggal :

I. Data Demografi Pasien

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II. Keluhan Utama

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III. Pengkajian Primer

a) Airway :
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Analisis Masalah Keperawatan :

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Analisis Etiologi Masalah Keperawatan :

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b) Breathing :
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Analisis Masalah Keperawatan :

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Analisis Etiologi Masalah Keperawatan :

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c) Circulation
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 Analisis Masalah Keperawatan :
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Anlisis Etiologi Masalah Keperawatan :

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d) Disability :
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Analisis Masalah Keperawatan :

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Analisis Etiologi Masalah Keperawatan :

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e) Eksprosure
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Analisis Masalah Keperawatan :

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Analisis Etiologi Masalah Keperawatan :

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B. PERENCANAAN KEPERAWATAN

NAMA PASIEN : .......................................... UMUR : …………………………………..

RUANGAN : .......................................... NO. REG : …………………………………..

NO DIAGNOSA INTERVENSI KEPERAWATAN

TUJUAN RENCANA RASIONAL
 IMPLEMENTASI KEPERAWATAN ( HARI KE- )

NAMA PASIEN : …………………………………….. UMUR : …………………………………. Diagnosa keperawatan :

RUANGAN : …………………………………….. NO. REG : ……………………………........

N PENGKAJIAN AWAL IMPLEMENTASI EVALUASI FORMATIF EVALUASI SUMATIF PARAF

O (S-O-A-P) (S-O-A-P)