DOKUMENTASI

ASUHAN KEPERAWATAN DI RUANG IGDTanggal pengkajian :...................................................

Pukul : ......................................A. PENGKAJIAN

1. Identitas Pasien

Nama

: .........................Umur

: ................ tahunJenis kelamin: .........................Alamat/No.telp: ..........................................................................................................................Pekerjaan: .....................................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

: ..................................................................................................

Nadi arteri radialis

: ..................................................................................................

Frekuensi nadi

: ..................................................................................................

Akral (hangat/dingin): ..................................................................................................

Perdarahan

: ..................................................................................................

..................................................................................................

..................................................................................................

d. Disabality (tingkat kesadaran)

Respon verbal: ..............................................................................................................

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 KEPERAWATAN1

2

3

4

5

6

C. PERENCANAAN dan IMPLEMENTASI

Tentukan prioritas (P1, P2, P3, P4)

.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

NoTglJamTindakanEvaluasi setelah tindakan

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D. EVALUASIAirway

Breathing

Circulation

Disability

Eksposure

Subang, ..(.........................................................)