Professional Documents
Culture Documents
Pukul : ......................................
A. PENGKAJIAN
1. Identitas Pasien
Nama
: .........................
Umur
: ................ tahun
: .....................................
Agama
: .........................
No. Register
: .....................................
2. Keluhan Utama
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
3. Riwayat Alergi
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
4. Riwayat Pengobatan Terakhir/Obat yang Telah atau Sedang Dikonsumsi
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
5. Riwayat Penyakit Dahulu
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
6. Riwayat Makanan yang Dikonsumsi Terakhir
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
7. Kondisi Lingkungan yang Berhubungan dengan Kejadian Trauma
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
8. Primary Survey
a. Airway (jalan nafas)
Look
: ..........................................................................................................................
Listen
: ..........................................................................................................................
Feel
: ..........................................................................................................................
b. Breathing (pernafasan)
Look
: ..........................................................................................................................
Frekuensi : ..........................................................................................................................
Sianosis
: ..........................................................................................................................
c. Circulation (sirkulasi)
Nadi arteri carotis
: ..................................................................................................
: ..................................................................................................
Frekuensi nadi
: ..................................................................................................
Akral (hangat/dingin)
: ..................................................................................................
Perdarahan
: ..................................................................................................
..................................................................................................
..................................................................................................
: ..............................................................................................................
Respon nyeri
: ..............................................................................................................
e. Eksposure (paparan)
Kepala belakang
: ..............................................................................................................
Punggung
: ..............................................................................................................
Panggul
: ..............................................................................................................
Kaki
: ..............................................................................................................
9. Secundary Survey
Kepala
:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Leher
:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Bahu
:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Dada
:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Perut
:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Genetalia :
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Punggung :
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Panggul :
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Tangan :
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Kaki
:
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
B. DIAGNOSA KEPERAWATAN
1
No
Tgl
Jam
Tindakan
No
Tgl
Jam
Tindakan
D. EVALUASI
Airway
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Breathing
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Circulation
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Disability
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Eksposure
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Malang,
April 2014
(.........................................................)