RESUME ASUHAN KEPERAWATAN KEGAWATDARURATAN

PADA TN. “D” DENGAN KLL DENGAN TRAUMA TUMPUL

Disusun Oleh :

Nama
NIM:

PROGRAM STUDI KEPERAWATAN S1 DAN NERS

SEKOLAH TINGGI ILMU KESEHATAN WIRA HUSADA
YOGYAKARTA
2021
 HALAMAN PENGESAHAN

Resume Asuhan Keperawatan Kegawatdaruratan

Pada TN. “D” dengan Diagnosa Medis KLL dengan Trauma Tumpul

Resume Asuhan Keperawatan ini telah dibaca dan diperiksa pada

Hari/tanggal: .................................................

Pembimbing Akademik Mahasiswa

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 FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

No. RM : ....................... Diagnosa Medis : ....................

IDENTITAS

Nama : ....................... Jenis Kelamin :L / P Umur : .................

Agama : ....................... Status Perkawinan : ................... Pendidikan : .................
Pekerjaan : ....................... Sumber informasi : ................... Alamat : .................

TRIAGE P1 P2 P3 P4 P5
GENERAL IMPRESSION
Keluhan Utama :

Mekanisme Cedera :

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...
Diagnosa Keperawatan
AIRWAY 1.

Jalan Nafas :  Paten  Tidak Paten Kriteria Hasil :

Obstruksi :  Lidah  Cairan  Benda Asing  N/A
Suara Nafas : Snoring Gurgling
Intervensi :
Stridor  N/A
1. Manajemen airway;headtilt-chin lift/jaw
Keluhan Lain : ........................................................................
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Diagnosa Keperawatan
BREATHING 1. Inefektif pola nafas b/d

Gerakan dada :  Simetris  Asimetris Kriteria Hasil :

Irama Nafas :  Cepat  Dangkal  Normal
Pola Nafas :  Teratur  Tidak Teratur
Intervensi :
Retraksi otot dada :  Ada  N/A
1. Pemberian terapi oksigen … …
Sesak Nafas :  Ada  N/A  RR : ... ... x/mnt
Keluhan Lain : ........................................................................
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Diagnosa Keperawatan
CIRCULATION 1. Penurunan curah jantung b/d
nefektif perfusi jaringan b/
Nadi :  Teraba  Tidak teraba Kriteria Hasil :
Sianosis :  Ya  Tidak
CRT :  < 2 detik  > 2 detik
PRIMER SURVEY

Intervensi :
Pendarahan :  Ya  Tidak ada
1.
Keluhan Lain: ..........................................................................
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Diagnosa Keperawatan
DISABILITY 1. Inefektif perfusi serebral b/d … … …
 Respon :  Alert  Verbal  Pain  Unrespon Kriteria Hasil :
Kesadaran :  CM  Delirium  Somnolen  ... ... ...
:  Eye ...  Verbal ...  Motorik ...
PRIMER SURVEY

GCS
Intervensi :
Pupil :  Isokor  Unisokor  Pinpoint  Medriasis
1. Berikan posisi head up 30 derajat
Refleks Cahaya:  Ada  Tidak Ada Periksa kesadaran dann GCS tiap
Keluhan Lain : ....................................................................
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Diagnosa Keperawatan
EXPOSURE 1. Kerusakan integritas jaringan b/d …
……
Kriteria Hasil :
Deformitas :  Ya  Tidak
Contusio :  Ya  Tidak
Abrasi :  Ya  Tidak
Penetrasi :  Ya  Tidak
Intervensi :
Laserasi :  Ya  Tidak
1. Perawatan luka
Edema :  Ya  Tidak
Heacting
Keluhan Lain:

Diagnosa Keperawatan
ANAMNESA 1. Regimen terapeutik inefektif b/d … …
…
Riwayat Penyakit Saat Ini : Kriteria Hasil :

Intervensi :
1.
Alergi :
SECONDARY SURVEY

Medikasi :

Riwayat Penyakit Sebelumnya:

Makan Minum Terakhir:

Even/Peristiwa Penyebab:

Tanda Vital :
BP : HR : S: RR :

Diagnosa Keperawatan
PEMERIKSAAN FISIK 1.
 Kepala dan Leher: Kriteria Hasil :
Inspeksi ................................................................................
Palpasi ................................................................................
Intervensi :
Dada:
1.
Inspeksi ................................................................................
Palpasi .................................................................................
Perkusi .................................................................................
SECONDARY SURVEY

Auskultasi .................................................................................
Abdomen:
Inspeksi ................................................................................
Palpasi ................................................................................
Perkusi ................................................................................
Auskultasi ................................................................................
Pelvis:
Inspeksi ................................................................................
Palpasi ................................................................................
Ektremitas Atas/Bawah:
Inspeksi ...............................................................................
Palpasi ...............................................................................
Punggung :
Inspeksi ................................................................................
Palpasi ................................................................................
Neurologis :
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Diagnosa Keperawatan
PEMERIKSAAN DIAGNOSTIK 1.

 RONTGEN  CT-SCAN  USG  EKG Kriteria Hasil :

 ENDOSKOPI  Lain-lain, ... ...
Hasil :
Intervensi :
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1.
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Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan :
NAMA TERANG : RAMADIN
Informasi Tambahan
1. Masalah Keperawatan yang ditemukan di UGD
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2. Tindakan Keperawatan dan Kolaboratif yang diberikan

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3. Rencana tindaklanjut yang diberikan kepada pasien (jika pasien dirawat)

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4. Penyuluhan Kesehatan untuk pasien dan keluarga (jika pasien tidak dirawat)
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 ANALISA MASALAH

No. Data Fokus Problem Etiologi

A. Diagnosa Keperawatan
1. ..............................................................................................................................................
2. ..............................................................................................................................................
3. ..............................................................................................................................................
4. ..............................................................................................................................................
5. ..............................................................................................................................................
B. Intervensi Keperawatan

Perencanaan
No Hari/Tgl/Jam Dx. Keperawatan
Tujuan dan Kriteria Hasil (NOC) Intervensi (NIC)
C. Implementasi & Evaluasi

No Paraf
Hari,Tanggal Implementasi Evaluasi (SOAP) lakukan diakhir shift jaga
Dx Nama

TINDAK LANJUT
Pulang / pindah ke : ..................................................................
Transportasi pindah : ..................................................................
Kondisi : baik / membaik / tetap / stabil / tidak stabil / kritis