Format Laporan Resume KGD

Tanggal pengkajian :

1. Data dasar :
a. Nama : ....................................................................................................................
b. Jenis kelamin : ....................................................................................................................
c. TTL (usia) : ....................................................................................................................
d. Pendidikan : ....................................................................................................................
e. Agama : ....................................................................................................................
f. Pekerjaan : ....................................................................................................................
g. Alamat : ....................................................................................................................
h. Diagnosa medis : ....................................................................................................................
i. Tgl pengkajian : ....................................................................................................................
j. Triage : ....................................................................................................................
k. Alasan : ....................................................................................................................

2. Keluhan utama :

3. Riwayat kesehatan/keperawatan :
a. Masa lalu : ......................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

b. Sekarang : ......................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

c. Keluarga : ......................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

4. Primary survey :

Airway + Control Servical

Breathing + Control
Ventilasi(Look & Listen)

Circulation + Control
Bleeding

Disability

Exposure
5. Masalah/Diagnosa keperawatan :

6. Tindakan utama (hasil dan rasional) :

Intervensi Hasil Rasional

7. Secondary survey :

Anamnesis : Riwayat “AMPLE’’

Allergic : ..................................................................................................................................
Medication:
.................................................................................................................................. ....................
Pass Ilnes: . ..................................................................................................................................
.................................................................................................................................. ....................
Last Meal: .................................................................................................................................. .
.................................................................................................................................. ....................
Event: . .................................................................................................................................. .......

Pemeriksaan Fisik (Head to toe Examination)

Keadaan umum Keadaan umum:
Kesadaran:
Hasil TTV: TD:................. mmHg, Sh: .......... ºC,
HR: ...... x/menit (85-155x/mnt), CRT ...... dtk,
RR: ...... x/menit(12-20x/mnt).
Kepala Bentuk:
keluhan:
Mata Konjungtiva :............., mata :.....................,
Sklera : ................., pupil : .................,
Refleks cahaya :............., palpebral :..............,
Bentuk : ..................,

Hidung ....................................................................................
....................................................................................
....................................................................................

Mulut ....................................................................................
....................................................................................
....................................................................................

Telinga ....................................................................................
....................................................................................
....................................................................................

Tengkuk/Leher ....................................................................................
....................................................................................
....................................................................................

Dada Dada: ....................................

Paru-paru: ............................
- Inspeksi : ........................................................
........................................................................
........................................................................
- Palpasi : ..........................................................
........................................................................
........................................................................
- Perkusi : .........................................................
........................................................................
- Auskultasi : .....................................................
........................................................................

Jantung: ................
- Inspeksi : ........................................................
........................................................................
........................................................................
- Palpasi : ..........................................................
........................................................................
........................................................................
- Perkusi : ..........................................................
........................................................................
- Auskultasi : .....................................................
........................................................................

Abdomen Perut : ...................

- Inspeksi : ........................................................
........................................................................
........................................................................
- Palpasi : ..........................................................
........................................................................
........................................................................
- Perkusi : ..........................................................
........................................................................
 - Auskultasi : .....................................................
........................................................................

Punggung ....................................................................................
....................................................................................
....................................................................................

Genitalia ....................................................................................
....................................................................................
....................................................................................

Ekstremitas Ekstremitas Atas : ....................................................

......................................................................................
......................................................................................
Ekstremitas Bawah : .................................................
......................................................................................
......................................................................................
Kekuatan Otot

Integumen ....................................................................................
....................................................................................
....................................................................................

8. Masalah/Diagnosa keperawatan :
..............................................................................................................................................................

9. Tindakan keperawatan (hasil dan rasional) :

Intervensi Hasil Rasional
10. Catatan perkembangan (+/-discharge plan) :

Subjektif :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

Objektif :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

Analisa :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

Planning: Intervensi dilanjutkan diruang rawat inap

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
 DAFTAR PUSTAKA

Brunner, & Suddarth. (2013). Buku Ajar Keperawatan Medikal Bedah, Buku Edisi 8
Vol2.Jakarta: EGC.
Ersila, W., & Prafitri, L. D. (2016). Buku Ajar Keperawatan Medikal Bedah Edisi
Yogyakarta:Salemba Medika.
Marimin (2018) BTCLS Plus AED. Jakarta: YGTC (Yayasan Global Training Centre)
Ns. Pirton Lumbantoruan, S.Kep (2015) BTCLS & Disaster Managemen. YPIKI (Yayasan
Pelatihan Ilmu Keperawatan Indonesia)
Nurarif, A. H., & Kusuma, H. (2015). Aplikasi Asuhan Keperawatan Berdasarkan
Diagnosa danNanda NIC NOC, Edisi 3. Jogjakarta: Mediaction. PPNI. (2016).
Standar DiagnosisKeperawatan Indonesia. Jakarta: DPP PPNI.
PPNI. (2018). Standar Luaran Keperwatan Indonesia. Jakarta: DPP PPNI.
PPNI. (2018). Standar ntervensi Keperawatan Indonesia. Jakarta: DPP
PPNI.Robbins. (2017). Buku Ajar Patologi, Edisi 2 Vol 2. Jakarta: EGC.
Safira. (2019). Anemia Pada Ibu Hamil, Konsep dan Pelaksanaan. DKI Jakarta: Cv. Trans Info
Medika.
Tarwoto, D. (2019). Anatomi dan Fisiologi Untuk Mahasiswa Keperawat. Jakarta:Trans Info
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