AKADEMI KEPERAWATAN BETHESDA TOMOHON

FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN GAWAT DARURAT

1. Identitas klien
Nama :
Umur :
Jenis kelamin :
Agama :
Pendidikan :
Pekerjaan :
Suku / bangsa :
Alamat :
Medical record :
Tanggal MRS / jam :
Tanggal pengkajian / jam :
Diagnosa medik :

2. Primary survey
Airway :

Breathing :

Circulation :

Disability :

Exposure :

3. Secondary survey
Keadaan umum :
Keluhan utama :

Riwayat Kesehatan Sekarang :

Riwayat Kesehatan Dahulu :

Riwayat Kesehatan Keluarga :

AKADEMI KEPERAWATAN BETHESDA TOMOHON

AMPLE (Allergy, Medication, Past illness, Last meal, Event leading) :

TTV :

Pemeriksaan fisik head to toe

(data terfokus) :

Pemeriksaan penunjang :

Pengobatan :

4. Pengelompokkan data
Data subjektif :

Data objektif :

5. Diagnosa keperawatan
1. .................................................................................

2. .................................................................................

3. .................................................................................

4. .................................................................................
AKADEMI KEPERAWATAN BETHESDA TOMOHON

6. Perencanaan keperawatan
Dx 1 : .......................................................................
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:........................................................................
Dx 2 : .......................................................................
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Dx 3 : .......................................................................
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:........................................................................
:........................................................................
:........................................................................
Dx 4 : .......................................................................
:........................................................................
:........................................................................
:........................................................................
:........................................................................

7. Implementasi keperawatan
Tanggal / jam Implementasi
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8. Evaluasi (SOAP)
Dx 1

Dx 2

Dx 3

Dx 4