PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN UNIVERSITAS NURUL JADID

KEPERAWATAN GAWAT DARURAT DAN KRITIS

Nama Mahasiswa : …………………....

NIM : ……………………
Ruangan : ……………………

A. IDENTITAS
1. Identitas Pasien
Nama :
Jenis Kelamin :
Tanggal Lahir :
Usia :
Tanggal Masuk RS :
No. Register :
Tanggal Pengkajian :
Diagnosa Medis :

2. Identitas Penanggung Jawab

Nama :
Usia :
Agama :
Pendidikan :
Pekerjaan :
Alamat Rumah :
No. Telp/HP :
B. KELUHAN UTAMA

C. RIWAYAT PENYAKIT SEKARANG

D. RIWAYAT KESEHATAN
1. Antenatal care
Perawatan antenatal (ANC) :
Tempat pemeriksaan ANC :
Komplikasi kehamilan :
Terpapar radiasi :
Golongan darah/Rhesus Ibu :
Golongan darah/Rhesus Ayah:
2. Intranatal
Tanggal lahir :
Tempat :
Penolong :
Jenis persalinan :
Komplikasi persalinan :
 3. Postnatal
Kondisi bayi saat lahir :
APGAR Score :
Usia gestasi :
Berat badan lahir :
Panjang badan lahir :
Reaksi alergi :

E. PENGKAJIAN FISIK
1. Pemeriksaan Umum
a. Keadaan Umum :
b. Kesadaran :
c. Tanda – tanda vital :
Nadi :
Suhu :
Pernafasan :
SpO2 :
d. Antropometri :
BB :
PB :
LD :
LILA :
LK :
2. Pemeriksaan Fisik
a. Kepala Leher
Kepala :
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Mata : ...............................................................................................................
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Hidung : ............................................................................................................
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Mulut :
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Telinga : ...................................................................................................
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Leher : ...................................................................................................
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b. Dada
Jantung : ...........................................................................................................
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Paru :
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c. Abdomen
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d. Genetalia dan Anus
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e. Ekstremitas
Ekstremitas Atas :
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Ekstremitas Bawah :
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 f. Eliminasi
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g. Nutrisi dan Cairan
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h. Refleks Fisiologis
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F. TERAPI
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G. PEMERIKSAAN PENUNJANG
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