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PROGRAM STUDI D-III KEPERAWATAN

FAKULTAS ILMU KESEHATAN


UNIVERSITAS MUHAMMADIYAH MAGELANG
Kampus II Jln. Mayjend Bambang Soegeng Mertoyudan Magelang 56172
Telp (0293) 326945 web: www.ummgl.ac.id
email:tatausahafikes@gmail.com

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT (RESUME)


Nama Mahasiswa
Semester/Tingkat
Tempat Praktek
Tanggal Pengkajian

:.........................................................................................................
:.........................................................................................................
:.........................................................................................................
:.........................................................................................................
DATA KLIEN

A. DATA UMUM
1. Nama inisial klien
2. Umur
3. Alamat
4. Agama
5. Tanggal masuk RS/RB
6. Nomor Rekam Medis
7. Bangsal

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

B. PENGKAJIAN PRIMER:
1. Airway (jalan nafas)
.................................................................................................................................. ..............
....................................................................................................................
2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, bantuan nafas, dll)
............................................................................................................................
............................................................................................................................
b. Palpasi (total fremitus, dll)
............................................................................................................................
............................................................................................................................
c. Perkusi (pembesaran paru, dll)
............................................................................................................................
............................................................................................................................
d. Auskultasi (suara nafas)
............................................................................................................................
............................................................................................................................
3. Circulation
a. Vital sign:
1) Tekanan darah :
2) Nadi
:
3) Suhu
:
4) Respirasi
:
b. Capilarry refill
:
c. Akral
:
4. Disability
a. GCS
E: .....
M: ........
b. Pupil
:
c. Gangguan motorik :

V: ......

d. Gangguan sensorik :

Tanggal/Jam

Subjektif

Objektif

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Assessment
(Laboratorium Dan
Therapy)

Plan

Implementasi

Evaluasi

Tujuan:
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Kriteria Hasil (NOC):
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Intervensi (NIC):
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