am pmam pm

Pengkajian Keperawatan IGD
PMH: Sistemik: HTN DM Cancer HIV Thyroid Anemia High lipids Neuro: CVA Seizure
J antung: MI Angina CHF CAD Paru: COPD Asthma GI : PUD GERD Liver
GU: UTI’s Stones MS: Arthritis Psych: Depression Anxiety Schizophrenia None
Alasan dirawat: ________________ _____________________________________________
Lainnya __________________________________________________________ ____________
Pengobatan: Tdk Lht Lampiran
________________________________________
______________________________________________________________________
______________________________________________________________________
Alergi: Tdk ada Latex __________________________________________________

SUB BAGIAN KGD
PSIK FK UGM

Keluhan Utama:

TRIASE: am pm

Datang dgn: Berjalan Kursiroda Teman Dibantu Ambulans Helikopter Polisi
Sumber: Pasien Keluarga Teman Perawat perujuk Polisi
Waktu: Onset________ Menit Jam Hari Minggu Bulan yll
Secara: Tiba-tiba Bertahap Nyeri: Masih Bertambah buruk Berkurang Hilang
Lokasi: Kn Kr Umum Frontal Occipital Parietal Temporal Retroorbital
Keparahan: Ringan Sedang Parah
Riwayat Lainnya:





________________________Ttd


PENGKAJIAN KEPERAWATAN: Ruang: am pm
Riwayat keperawatan: Review Pengkajian Triase
Sumber: Pasien Keluarga Teman Perwata perujuk Polisi
Prehospital: RJP Intubasi O2 IV C-collar Backboard Bidai Obat _________Tdk ada
Context Circumstances: Spontaneous Recent stress Febrile illness Trauma CO exposure
Associated signs and symptoms: None
Fever N V Weakness Numbness Photophobia Blurred vision
Nasal congestion Lacrimation Aura: Visual Sensory Motor Mood
Other history:






Nursing exam:
Constitutional: Alert Well-appearing Ill-appearing Confused Poorly responsive
Respiratory: R L Bil Wheezes Rales Rhonchi normal
CV: Tachycardia Bradycardia Irregular normal
Neurologic: Oriented to: Time Person Place Not oriented Unable to test normal
Motor function: R L Arm Leg Face Weak Unable to test normal
Other exam:


DIAGNOSA KEPERAWATAN:
1.
2.
3.

RENCANA KEPERAWATAN:




KRITERIA HASIL:


_______________________________________Ttd


Tanda-tanda Vital Triase
S N RR TD


Sat O2 Nyeri
Kg



Tingkat Triase

Emergent Urgent Nonurgent

Instruksi, Intervensi, dan Hasil
Instruksi yg dijalankan atau intervensi iyg
dilakukan Sebelum evaluasi Dokter:
Pvt MD notified: YA TIDAK
Accucheck ________________
O2: ________________________
IV: ________________________
Monitor ____________________
EKG ________________
XR: _______________________
Labs: _________________________
Test kehamilan urin
Pengelolaan pernapasan__________
Splint(s) ____________________
Dressing (s) __________________
Tetanus (lihat form pengobatan)
Lainnya: ______________________
Lainnya: ______________________
Hasil
Accucheck _________ Repeat _________
Urine Dip SpG _________ Ket _________














































INTERVENSI LAINNYA
TRAUMA / SURGICAL

C-collar applied ________________

Ortho care ____________________

Ice Elevation

Ace Sling Splint Brace

Shoulder immobilizer Strapping

Knee immobilizer Shoe

Crutch education

Wound care ___________________

Topical anesthesia ____________

Wound prep _________________

Adhesive ___________________

Suturing Staple ____________

Burn care _____________________

Fracture care __________________

I and D _______________________

Arthrocentesis _________________

Chest tube

CARDIOPULMONARY

O2: 4 L NC Mask NRB

Pulse ox: Spot Continuous

Monitor NSR

Rhythm strip __________________

EKG: ED EKG tech

Intubation ____________________

CPR ACLS ___________________

Cardioversion _________________

External pacemaker _____________

CVP placement ________________

Respiratory treatment ___________

Sputum collection ______________

IV Thrombolysis _______________

ABDOMINAL / PELVIC

NG: Size _____ ______________

Gastric lavage: NG Oral

Foley: Size _____ ____________

I and O urine cath ______________

Vomiting management __________

Incontinence management ________

Disimpaction __________________

Enema Type _________________

Sexual assault exam ____________

EYE / ENT

Topical anesthesia ______________

Eye irrigation _____cc of ________

Ear wax/FB removal ___________

Nasal FB removal ______________

Epistaxis control _______________

Laryngoscopy _________________

LAIN-LAIN

Lab draw: ED Lab tech

XR: Patient departed

Patient returned

Injection X 1 2 3 4

Restraints 2 3 4 point

Reassessment _______________

Lumbar puncture Dr. Sim

Blood transfusion ______________

Conscious sedation _____________

Isolation for ___________________
Waktu S N RR TD Sat 02 Nyeri








INSTRUKSI PENGOBATAN DAN IV
Waktu

Cairan, Pengobatan Jumlah
/Dosis
Rute Site

Ukuran

Pump Rate Oleh
(Inisial)









Kode Site 1. Deltoid 2. Glutueus 3. Paha anterior 4. Paha lateral 5. Fossa antecubital 6. Lengan
7. Tangan 8. Kaki 9. Leher 10. Intraosseus

Waktu CATATAN KEPERAWATAN Inisial


















Pemberi asuhan #1 Pemberi asuhan #3
Pemberi asuhan #2 Pemberi asuhan #4

DISPOSISI
Discharged LWBS AMA Expired Admitted Transferred to: Transfer form
completed
Mode of departure: Walking Carry Wheelchair Cart Auto Ambulance MediVan _________________________________
Condition on D/C: Pain scale: NA Improved Worsened Good Fair Poor Stable Unstable Critical
Verbalizes understanding of discharge instructions Barriers to understanding or learning
___________________________
Written Verbal instructions given to: Report called by:
Patient Parent Caregiver ___________________________ Report called to: S
Referred to: _______________________PRN / in ________ days D/C ed by: ___________________________