DOKUMENTASI

ASUHAN KEPERAWATAN DI RUANG IGD

Tanggal pengkajian : ...................................................

Pukul : ......................................

A. PENGKAJIAN
1. Identitas Pasien
Nama

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

Umur

: ................ tahun

Jenis kelamin : .........................

Alamat/No.telp : ..........................................................................................................................
Pekerjaan

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

Agama

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

No. Register

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

2. Keluhan Utama
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3. Riwayat Alergi
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4. Riwayat Pengobatan Terakhir/Obat yang Telah atau Sedang Dikonsumsi
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5. Riwayat Penyakit Dahulu
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6. Riwayat Makanan yang Dikonsumsi Terakhir
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7. Kondisi Lingkungan yang Berhubungan dengan Kejadian Trauma
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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

: ..................................................................................................
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d. Disabality (tingkat kesadaran)

Respon verbal

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

Respon nyeri

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

e. Eksposure (paparan)
Kepala belakang

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

Punggung

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

Panggul

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

Kaki

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

9. Secundary Survey
Kepala
:
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Leher
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Bahu
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Dada
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Perut
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Genetalia :
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Punggung :
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Panggul :
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Tangan :
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Kaki
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B. DIAGNOSA KEPERAWATAN
1

C. PERENCANAAN dan IMPLEMENTASI

Tentukan prioritas (P1, P2, P3, P4)
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No

Tgl

Jam

Tindakan

Evaluasi setelah tindakan

No

Tgl

Jam

Tindakan

Evaluasi setelah tindakan

D. EVALUASI

Airway
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Breathing
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Circulation
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Disability
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Eksposure
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Malang,

April 2014

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