FORMAT LAPORAN PENDAHULUAN

ASUHAN KEPERAWATAN KRITIS

PROGRAM STUDI KEPERAWATAN

1. COVER
2. PENGERTIAN
3. ETIOLOGI
4. MANIFESTASI KLINIS
5. PATHOFISIOLOGI
6. PATHWAY
7. PEMERIKSAAN PENUNJANG
8. KOMPLIKASI
9. PENATALAKSANAAN
10. PENGKAJIAN KEPERAWATAN
a. Primary survey
1) Airway
2) Breathing
3) Circulation
4) Disability
5) Exposure
b. Secondary Survey
c. Pemeriksaan Penunjang
d. Diagnosa Keperawatan Primer
e. Diagnosa Keperawatan Sekunder
f. Intervensi Keperawatan
g. Implementasi
h. Evaluasi
11. DAFTAR PUSTAKA
 FORMAT LAPORAN ANALISA SINTESA
RUANG GAWAT DARURAT

Nama Mahasiswa :.................... No. BP :..................

Nama Pasien :.................... Umur :..................
Diagnosa Medis :..................................................................................

Laporan dibuat setiap hari, dan di kumpul setiap minggu

1. Pengkajian primer (Airway, breathing, circulation, disability, exsprosure)

Airway
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Breathing
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Circulation
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Disability
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Ekposure
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2. Diagnosa keperwatan (berdasarkan pengkajian primer, mengikuti pola PES)
...................................................................................................................................................
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3. Intervensi keperawatan primer ( untuk mengatasi masalah dari hasil pengkajian primer)
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4. Implementasi keperawatan primer
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..................................................................................................................................................
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4. Evaluasi keperawatan primer
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5. Pengkajian sekunder (meliputi pengkajian riwayat kesehatan dan pengkajian head to

toe)
...................................................................................................................................................
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6. pemeriksaan penunjang ( pemeriksaan laboratorium, X-Ray, EKG, CT scan, dll)
...................................................................................................................................................
...................................................................................................................................................
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7. Diagnosa keperawatan Sekunder (berdasarkan hasil pengkajian sekunder dan
pemriksaan penunjang, mengikuti pola PES, minimal 3 diagnosa)
...................................................................................................................................................
...................................................................................................................................................
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 8. Intervensi keperawatan Sekunder
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.
9. Implementasi
..................................................................................................................................................
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10. Evaluasi
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11. WOC
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