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  • CamScanner 12-23-2022 18.44

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    Fajar Mustafa
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    12 views10 pages

    CamScanner 12-23-2022 18.44

    Uploaded by

    Fajar Mustafa

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 10
    SEKOLAH TINGGI ILMU KESEHATAN NGUDIA HUSADA MADURA Program Study SI Iinu Keperawatan - Program Praktek Profesi Ners (031) 3061522 — Bangkalan-Madura 69116. FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURA1 (Ruang: uRSUD.. i 1 Hdenttas en 1, Nama TS 2. NoRM ooo 3. Usia 74 thn 4. Jeniskelamin —: Lok -Laki 5. Alamat Sucabayer 6 Pendidikan 31 ¢N 7. Agama Istone & Status ‘Menikah 9, SulwBangsa —:[ydone sia. 10, Tangesl MRS :22 Desewber 2022 11, Tangaa penghajian: 22, Desember 202% 12. Ruangan co 13, Diagnosa meds: General weakness + Vomiting + OFH2 TL, Wentitas penanggung java 1 Nama M 2 Ue crn 2. Jeniekelamin—_: Perewpvcin 4. Agama tone 5. Soka ndowesie © Hb dengan len :isbvi 7. Alamat Surabaya MH Keluhan utama 7 Demam daw lewas. 1¥. vaya peng para cone ten dat ang 4 reson . i . ea tent) ar geyal eu igs felncloa dau sauied muintak FewGrin = 2 Fal eee samp latan i pattie rc Dipindai dengan CamScanner wv. Primary Survey ‘A: Airy (Jalan nafas) sone AOW.a FAS. spontan Lb VIL. Pemeriksaan Head to toe No TEM ‘YANG DIAMATI: T__[ KEADAAN UMUM 2._ | KESADARAN EA: © M6 (compos ments) 3. | TANDA—TANDA VITAL TD” <1H0/go wnttg SUH : 38 °C RR: 20x/menil NADL: 103% (went a [INTEGUMENT? INSPEKST KULIT 1. Kul Bilouk werala dau benloa ‘et clubbing fisgee pda oes... 7 PALPAST 1. Kult: 5. | KEPALA Dipindai dengan CamScanner >| MATA WAJAT, HIDUNG MULUT TELINGA 2, Telinga 1. Amalia mt goutut belinga sien ba a at TEHER DADA/THORAK PALPAST: ictus cordis Leraba, Dipindai dengan CamScanner 13. [ABDOMEN eS. JostOf. ‘peetuenn bien 14, | EKSTRIMITAS 15. | GENETALIA 16. ANUS ~Tudat Kerkay: Dipindai dengan CamScanner ANALISA DATA 1 0000%%4 Nama Pasien : Th $ No.RM Umur 274 Uw Ruang 7 NO DATA (DSIDO) PROBLEM ETIOLO %[De=-fasien meagatatan — |HiferLerwia | Pebidvas bertenugal davi Ladi tnalayy Do: Hail observars Liv TD 140/90 wtlg NHl02¥/wenit 5p0,:98% Cs foulau) S38 > Sulu tubul, diabas Wil’ moral 2% [05 -Rasien mengalatan wash moet Nousea Peuiugtatan ceteuan tutraabdonina] D0:-Has! obserari Lv 1D:140/90 wml N03 x

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