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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT (UNIT GAWAT DARURAT) Nama Mahasiswa : NIM : Tempat Pengkajian : Tanggal : I. Identitas Klien 1. Nama: 2. No RM: 3. Umur: 4. Alasan masuk RS 5. Diagnosa medis: II. Pengkajian A. Primary survey 1. Respon …………….. …………………………………………………………………………………………………………………………………………………………………… ………...…………………………………………………………………………………………………... ………………………………………………………………………….................................. .............................................................. .............................................................. ................................ 2. Airway …………….. …………………………………………………………………………………………………………………………………………………………………… ………...…………………………………………………………………………………………………... …………………………………………………………………………..................................

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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

(UNIT GAWAT DARURAT)

Nama Mahasiswa :NIM : Tempat Pengkajian :Tanggal :

I. Identitas Klien1. Nama:2. No RM:3. Umur:4. Alasan masuk RS

5. Diagnosa medis:

II. Pengkajian A. Primary survey1. Respon

……………..……………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………..............................................................................................................................................................................................

2. Airway……………..……………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………..............................................................................................................................................................................................

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3. Breathing……………..……………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………...………………………………………………………………………….............................................................................................................................................................................................

……………………………………………………………………….............................................................................................................................................................................................

4. Circulation……………..……………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………..............................................................................................................................................................................................……………………………………………………………………….............................................................................................................................................................................................

5. Disability ……………..……………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………..............................................................................................................................................................................................……………………………………………………………………….............................................................................................................................................................................................

6. Exposure ……………..……………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………..............................................................................................................................................................................................……………………………………………………………………….............................................................................................................................................................................................

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B. Secondary survey1. Riwayat penyakit sekarang

……………..……………………………………………………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………...………………………………………………………………………….................................

2. Riwayat kesehatan terdahulu:

a. Penyakit yang pernah dialami

.…………………………………………………………………………………………….......

…………..……………………………………………………………………………………..

b. Alergi (obat, makanan, dll)

.…………………………………………………………………………………………….......

c. Obat-obat yang digunakan

.…………………………………………………………………………………………….......

………………………………………………………………………………………………….

3. Pengkajian Head to toe

Keadaan umum ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Tanda vital & nyeri

……………………………………………………………………………………………………………………………………………………………………………………………………

a. Kepala……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b. Leher.……………………………………………………................................................................

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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

c. Dada.………………………………………………………………………………………...….…………………………………………………………………………………………...……………………………………………………………………………………………………………………………………………………………………………………………………...............…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

d. Abdomen.…………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

e. Urogenital ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

f. Ekstremitas ..……………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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……………………………………………………………………………………………………………………………………………………………………………………………………

g. Punggung ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

h. Keadaan lokal .

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7. Tindakan prehospital.………………………………………………………………………………………...….…………………………………………………………………………………………...……………………………………………………………………………………………………………………………………………………………………………………………………...............…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

8. Pemeriksaan penunjang.………………………………………………………………………………………...….…………………………………………………………………………………………...……………………………………………………………………………………………………………………………………………………………………………………………………...............…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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ANALISA DATA

NO DATA PENUNJANG MASALAH ETIOLOGI

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RENCANA KEPERAWATAN

NO DIAGNOSA KEPERAWATAN

TUJUAN DAN KRITERIA HASIL

INTERVENSI RASIONAL

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CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI