FORMAT RESUME KEPERAWATAN GAWAT DARURAT

PRODI PROFESI NERS POLTEKKES KEMENKES PONTIANAK

Jln. 28 Oktober Siantan Hulu Pontianak

Nama Mahasiswa : ..................................................................................

NIM : ..................................................................................
Ruangan / RS : ..................................................................................
Tanggal / Hari Pengkajian : ............................................ Jam : ............. WIB

I. IDENTITAS KLIEN
Inisial Klien : ........................... No. Reg/RM : .............................
Umur : ................. tahun Tgl. MRS : .............................
Jenis Kelamin : ........................... Diagnosa : .............................
Suku/Bangsa : ........................... .............................
........................... Patient’s Label : .............................
Agama : ...........................
Pekerjaan : ...........................
Pendidikan : ...........................
Alamat : ............................................................................................
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Penanggung : BPJS / UMUM

II. TRIAGE
 Penyakit Berat Yang Pernah Diderita
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 Obat – Obatan Yang Biasa Dikonsumsi
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 Kebiasaan Berobat
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  Alergi
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 Riwayat Penyakit Sekarang
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 Keluhan Utama MRS
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 Keluhan Utama Saat Ini
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 Tanda – Tanda Vital
TD : ...................... mmHg RR : ........................x/menit
HR : .....................x/menit S : ................................ºC
SpO2 : ..............................%

III. PENGKAJIAN
1. Pengkajian Primer ( Primary Assessment )
 Airway
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 Breathing
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 Circulation
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 Disintegrasi / Disability
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 Exposure
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2. Pengkajian Sekunder ( Secondary Assessment )

 Anamnesa
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 Kepala
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 Mata
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 Hidung
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 Mulut dan Tenggorokan
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 Dada dan Paru – Paru
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 Jantung dan Sirkulasi
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 Abdomen
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 Genetalia dan Reproduksi
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 Status Neurologis
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 Ekstremitas
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IV. PEMERIKSAAN PENUNJANG
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V. TERAPI MEDIKASI
No. Tanggal Terapi Dosis Jalur
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Tanda Tangan

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