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 (Air way, 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/SDKI)

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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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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