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    Format Asuhan Keperawatan Gawat Darurat (Trauma)

    Uploaded by

    Faiqotun Nazila
    The document appears to be a template for nursing care plans for emergency or urgent care patients presenting with either trauma or non-trauma related issues. The template includes sections for collecting the patient's identity and background, subjective and objective assessment data, examination findings, diagnostic testing, and treatment plan. It will be used to guide the nursing assessment and care for an individual presenting in urgent/emergency care.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Format Asuhan Keperawatan Gawat Darurat (Trauma)

    Uploaded by

    Faiqotun Nazila
    26 views5 pages
    The document appears to be a template for nursing care plans for emergency or urgent care patients presenting with either trauma or non-trauma related issues. The template includes sections for collecting the patient's identity and background, subjective and objective assessment data, examination findings, diagnostic testing, and treatment plan. It will be used to guide the nursing assessment and care for an individual presenting in urgent/emergency care.

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    Asuhan gawat darurat

    Original Title

    Format Askep Gadar

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    The document appears to be a template for nursing care plans for emergency or urgent care patients presenting with either trauma or non-trauma related issues. The template includes sections for collecting the patient's identity and background, subjective and objective assessment data, examination findings, diagnostic testing, and treatment plan. It will be used to guide the nursing assessment and care for an individual presenting in urgent/emergency care.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    26 views5 pages

    Format Asuhan Keperawatan Gawat Darurat (Trauma)

    Uploaded by

    Faiqotun Nazila
    The document appears to be a template for nursing care plans for emergency or urgent care patients presenting with either trauma or non-trauma related issues. The template includes sections for collecting the patient's identity and background, subjective and objective assessment data, examination findings, diagnostic testing, and treatment plan. It will be used to guide the nursing assessment and care for an individual presenting in urgent/emergency care.

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    © All Rights Reserved
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    of 5

    STIKES Hafshawaty Nama Mahasiswa :………………………..

    Pesantren Zainul Hasan NIM : ……………………….


    Rumah Sakit : ……………………….

    FORMAT ASUHAN KEPERAWATAN


    GAWAT DARURAT (TRAUMA)

    I. IDENTITAS
    Nama : ……………………………………..
    Umur : ……………………………………..
    Jenis Kelamin :……………………………………..
    Agama : ……………………………………..
    Suku / Bangsa :...........................................................
    Alamat : ……………………………………..
    Agama : ……………………………………..
    Pendidikan : ……………………………………..
    Pekerjaan : ……………………………………..
    Diagnosa Medis : ……………………………………..
    No. Register : ……………………………………..
    Tanggal Pengkajian : ………………………Jam :……….
    Sumber Informasi :..........................................................

    II. DATA SUBYEKTIF


     KELUHAN UTAMA SAAT PENGKAJIAN
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     RIWAYAT PENYAKIT SEKARANG ( MEKANISME TRAUMA )
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     RIWAYAT PENYAKIT YANG LALU
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     RIWAYAT ALERGI
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     PENGOBATAN YANG DIGUNAKAN SELAMA INI
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     MAKAN TERAKHIR
    …………………………………………………………………………………………

    III.DATA OBYEKTIF
    A AIRWAY
    ……………………………………………………………………………………
    B BREATHING
    ……………………………………………………………………………………
    C CIRCULATION
    ……………………………………………………………………………………
    D DISABILITY
    ……………………………………………………………………………………
    E EXSPOSURE
    ……………………………………………………………………………………
    F FULL VITAL SIGN
    ……………………………………………………………………………………
    G GIVE COMFORT
    ……………………………………………………………………………………
    H HEAD TO TOE
    a. Penampilan Umum
    ……………………………………………………………………………………
    b. Tanda – Tanda Vital :
    TD :………mmHg Nadi :………x/mnt RR :………x /mnt Suhu………º C
    c. Kepala dan Leher
    ……………………………………………………………………………………
    d. Mata
    ……………………………………………………………………………………
    e. Telinga
    ……………………………………………………………………………………
    f. Hidung
    ………………………………………………………………………………………
    g. Mulut
    ……………………………………………………………………………………
    h. Thorak / dada
    ……………………………………………………………………………………
    i. Abdomen
    ………………………………………………………………………………………
    j. Genetalia
    ……………………………………………………………………………………
    k. Anus
    ……………………………………………………………………………………
    l. Muskuloskeletal
    ……………………………………………………………………………………
    m. Integumen
    ……………………………………………………………………………………
    n. Neurologi
    ……………………………………………………………………………………

    I INSPEKSI BACK / POSTERIOR


    ……………………………………………………………………………………

    IV. PEMERIKSAAN PENUNJANG


    ……………………………………………………………………………………
    V. PENATALAKSANAAN
    ……………………………………………………………………………………

    ………………,……………..200….
    Pembimbing Ruangan Nama Mahasiswa

    ……………………….. ……………………
    STIKES Hafshawaty Nama Mahasiswa :…………………………
    Pesantren Zainul Hasan NIM : ………………………..
    Ruangan : ……………………….

    FORMAT ASUHAN KEPERAWATAN


    GAWAT DARURAT ( NON TRAUMA )

    I. IDENTITAS
    Nama : ……………………………………..
    Umur : ……………………………………..
    Agama : ……………………………………..
    Alamat : ……………………………………..
    Agama : ……………………………………..
    Pendidikan : ……………………………………..
    Pekerjaan : ……………………………………..
    Tanggal MRS : ……………………………………..
    Diagnosa Medis : ……………………………………..
    No. Register : ……………………………………..
    Tanggal Pengkajian : ……………………………………..

    II. DATA SUBYEKTIF


     KELUHAN UTAMA SAAT PENGKAJIAN
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     RIWAYAT PENYAKIT SEKARANG
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     RIWAYAT PENYAKIT YANG LALU
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     RIWAYAT ALERGI
    …………………………………………………………………………………………
    …………………………………………………………………………………………
     PENGOBATAN YANG DIGUNAKAN SELAMA INI
    …………………………………………………………………………………………
    …………………………………………………………………………………………
    III. DATA OBYEKTIF
    A. AIRWAY
    ……………………………………………………………………………………
    ……………………………………………………………………………………
    B. BREATHING
    ……………………………………………………………………………………
    ……………………………………………………………………………………
    C. CIRCULATION
    ……………………………………………………………………………………
    ……………………………………………………………………………………
    D. DISABILITY
    ……………………………………………………………………………………
    ……………………………………………………………………………………
    IV. PENGKAJIAN HEAD TO TOE
    a. Penampilan Umum
    …………………………………………………………………………………………
    b. TTV : TD……………HR……………RR…………Suhu……………..
    c. Kepala dan Leher
    …………………………………………………………………………………………
    d. Mata
    …………………………………………………………………………………………
    e. Telinga
    …………………………………………………………………………………………
    f. Hidung
    …………………………………………………………………………………………
    g. Mulut
    …………………………………………………………………………………………
    h. Thorak / dada
    …………………………………………………………………………………………
    i. Abdomen
    …………………………………………………………………………………………
    j. Genetalia
    …………………………………………………………………………………………
    k. Anus
    …………………………………………………………………………………………
    l. Muskuloskeletal
    …………………………………………………………………………………………
    m. Integumen
    …………………………………………………………………………………………
    n. Neurologi
    …………………………………………………………………………………………

    V. PEMERIKSAAN PENUNJANG
    …………………………………………………………………………………………
    …………………………………………………………………………………………

    VI. PENATALAKSANAAN
    …………………………………………………………………………………………
    …………………………………………………………………………………………

    ………………,……………..201….
    Pembimbing Ruangan Nama Mahasiswa

    ……………………….. ……………………
    VII. PEMERIKSAAN FISIK
    a. Penampilan Umum
    …………………………………………………………………………………………
    b. TTV : TD……………HR……………RR…………Suhu……………..

    c. Kepala dan Leher


    …………………………………………………………………………………………
    d. Mata
    …………………………………………………………………………………………
    e. Telinga
    …………………………………………………………………………………………
    f. Hidung
    …………………………………………………………………………………………
    g. Mulut
    …………………………………………………………………………………………
    h. Thorak / dada
    …………………………………………………………………………………………
    i. Abdomen
    …………………………………………………………………………………………
    j. Genetalia
    …………………………………………………………………………………………
    k. Anus
    …………………………………………………………………………………………
    l. Muskuloskeletal
    …………………………………………………………………………………………
    m. Integumen
    …………………………………………………………………………………………
    n. Neurologi
    …………………………………………………………………………………………

    VIII. PEMERIKSAAN PENUNJANG


    …………………………………………………………………………………………
    …………………………………………………………………………………………
    IX. PENATALAKSANAAN / TERAPI
    …………………………………………………………………………………………
    …………………………………………………………………………………………

    ………………,……………..201….
    Pembimbing Ruangan Nama Mahasiswa

    ……………………….. ……………………

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