Case Resume

Emergency Of Nursing
Student Name :

Hospital :

Date assessment :

1. Basic Data

a. Name :

b.Gender :

c. Date of birth/Age :

d.Last education :

e. Religion :

f. Occupation :

g.Adress :

h.Medical Diagnosis :

i. Triage :

j. Argument :

2. Main complaint
3. Medical history/Nursing history
a. Last medical history

b. Currently medical history

c. Family medical history

4. Primary Survey
a. AIRWAY

b. BREATHING

c. CIRCULATION

d. DISSABILITY

e. EXPOSURE

f. FOLLEY CATHETER

g. GASTRIC TUBE

h. HEART MONITOR
5. Nursing Diagnosis

6. Primary intervention (result and evaluation)

7. Secondary survey

a. SAMPLE
1) Sign and symptoms

2) Allergy

3) Medications

4) Past history

5) Last meal/medication

6) Even leading
b. Head to toe examinations
c. Radiology and laboratorium
 Data Analysis

NO DATA ETIOLOGY PROBLEM

Nursing Interventions

Nursing
No Directions Intervension Rationalist
Diagnosis
 Nursing Implementations and result

Nursing Evaluation/discharge plan

Date/Time Implementations TTD
Diagnosis (SOAP)
 DAILY REPORT TRIAGE

No No Name Age Miedical Main Triage Argument

Register Diagnosis Complaint category

10

11
12

13

14

15