FORMAT
ASUHAN KEPERAWATAN GAWAT DARURAT
SARJANA
KEPERAWATAN STIKes KESOSI
|
Nama
Mahasiswa
|
:
|
...................................
|
Tanggal
|
:
|
...................................
|
|
NIM
|
:
|
...................................
|
Tempat
|
:
|
...................................
|
|
Inisial
Klien
|
:
|
...................................
|
Dx
Medik
|
:
|
...................................
|
I. Pengkajian
Primer
A. Data
Fokus
Airway : ............................................................................................................................
Breathing :
............................................................................................................................
Circulation :
............................................................................................................................
Disability :
............................................................................................................................
Exposure :
............................................................................................................................
B. Diagnosa
Keperawatan Utama
.......................................................................................................................................................
.......................................................................................................................................................
C. Rasional
Diagnosa Keperawatan Utama
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
D. Tindakan
Keperawatan yang Dilakukan dan Rasionalnya
|
Tindakan Utama
|
Rasional
|
|
1.
Treatment
a.
............................................................
b.
............................................................
c.
............................................................
2.
Diagnostik
a.
............................................................
b.
............................................................
c.
............................................................
|
a.
............................................................
b.
............................................................
c.
............................................................
a.
............................................................
b.
............................................................
c.
............................................................
|
E. Prinsip
Tindakan
.......................................................................................................................................................
.......................................................................................................................................................
F. Evaluasi
S :
.................................................................................................................................................
O :
.................................................................................................................................................
A :
.................................................................................................................................................
P :
.................................................................................................................................................
G. Bahaya
yang Mungkin Timbul (Komplikasi) Akibat Tindakan Tersebut (Jika Ada):
.......................................................................................................................................................
.......................................................................................................................................................
H. Tindakan
Keperawatan Lain yang Dapat Dilakukan Untuk Mengatasi Masalah Tersebut
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
I. Evaluasi
Diri
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
II. Pengkajian
Sekunder
A. Keluhan
Utama
.......................................................................................................................................................
.......................................................................................................................................................
B. Riwayan
Kesehatan
Sign & Symptom : ................................................................................................................
Alergi :
................................................................................................................
Medikasi : ................................................................................................................
Provokasi :
................................................................................................................
Environment : ................................................................................................................
Last Meal :
................................................................................................................
C. Riwayat
Trauma
.......................................................................................................................................................
.......................................................................................................................................................
D. Pemeriksaan
Fisik
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
E. Labor
& Diagnostik
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
F. Diagnosa
Keperawatan Prioritas
.......................................................................................................................................................
.......................................................................................................................................................
G. Tindakan
Keperawatan
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
H. Rencana
Tindak Lanjut/Follow Up/Pulang, dll
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
