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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IDENTITAS FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

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

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.

  Kriteria Hasil :
Jalan Nafas : Paten Tidak Paten
   
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

  Kriteria Hasil :
Gerakan dada : Simetris Asimetris
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   Kriteria Hasil :
: Teraba Tidak teraba
Sianosis  
: Ya Tidak
 
CRT
SURVEY

: < 2 detik > 2 detik

  Intervensi :
Pendarahan : Ya Tidak ada 1.
Keluhan Lain:
...................................................................................................
PRIMER

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Diagnosa Keperawatan
DISABILITY 1. Inefektif perfusi serebral b/d … … …
 Respon     Kriteria Hasil :
: Alert Verbal Pain Unrespon
   
... ... ...Kesadaran: CM Delirium Somnolen
  
SURVEY

GCS : Eye ... Verbal ... ... Motorik

Pupil     Intervensi :
: Isokor Unisokor Pinpoint Medriasis 1. Berikan posisi head up 30 derajat
  Periksa kesadaran dann GCS tiap
Refleks Cahaya: Ada Tidak Ada
Keluhan Lain : ....................................................................
PRIMER

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Diagnosa Keperawatan
EXPOSURE 1. Kerusakan integritas jaringan b/d …
……
Deformitas   Kriteria Hasil :
Tidak: Ya
 
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 :

Alergi : 1.
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................................................................................
Dada: Intervensi :
1.
Inspeksi ................................................................................
Palpasi.................................................................................
SURVEY

Perkusi.................................................................................
Auskultasi .................................................................................
Abdomen:
Inspeksi ................................................................................
SECONDARY

Palpasi................................................................................
Perkusi................................................................................
Auskultasi ................................................................................
Pelvis:
Inspeksi ................................................................................
Palpasi................................................................................
Ektremitas Atas/Bawah:
Inspeksi ...............................................................................
Palpasi...............................................................................
Punggung :
Inspeksi ................................................................................
Palpasi................................................................................
Neurologis :
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....................................................................................................

Diagnosa Keperawatan
PEMERIKSAAN DIAGNOSTIK 1.

    Kriteria Hasil :
RONTGEN CT-SCAN USG EKG
 
ENDOSKOPI Lain-lain, ... ...
Hasil :
................................................................................................... Intervensi :
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

No Hari/Tgl/Jam Dx. Keperawatan Perencanaan

Tujuan dan Kriteria Hasil (NOC) Intervensi (NIC)
C. Implementasi & Evaluasi

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

Dx Nama

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