FORMULIR PENGKAJIAN (KELOLAAN)

KEPERAWATAN KRITIS DI UGD

PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KESEHATAN
UNIVERSITAS GRESIK

Nama Mahasiswa :
NIM :
Ruangan :
Pengkajian diambil : Jam :
Diagnosa Medis : No.Rekam Medik :

A. IDENTITAS PASIEN IDENTITAS PENANGGUNG JAWAB

Nama : Nama :
Umur : Umur :
Jenis Kelamin : Jenis Kelamin :
Suku : Suku :
Agama : Agama :
Pendidikan : Pendidikan :
Alamat : Alamat :

B. RIWAYAT KEPERAWATAN

1. Keluhan Utama
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2. Riwayat penyakit sekarang
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3. Riwayat penyakit sebelumnya
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4. Riwayat kesehatan keluarga
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5. Mekanisme Trauma (Khusus Kasus Trauma)
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6. Pemeriksaan Fisik
B1 (Breath)
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B2 (Blood)
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B3 (Brain)
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 B4 (Bladder)
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B5 (Bowel)
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B6 (Bone)
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7. Pemeriksaan Penunjang dan Terapi

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

Vital Sign Analisa Gas Darah

Waktu

HCO2
TD RR Nadi Suhu pH PCO2 PO2 A:a DO 2 BE
O2 Sat
07.00

08.00

09.00

10.00

11.00

12.00

13.00

14.00

15.00

16.00

17.00

18.00

19.00

20.00

21.00

22.00

23.00

24.00

01.00

02.00

03.00

04.00

05.00

06.00
 Nama Pasien : ...........................
Umur : ...........................
Diagnosa Medis : ...........................
Tanggal : ...........................

Waktu Medikasi / Dosis Tempat Pemberian Jumlah Tanda

Pemberian infus Tetesan Tangan

Tanggal / Pengeluaran Keterangan

Waktu Urine Emesis NGT BAB