PEMERINTAH KABUPATEN WAJO

UPTD PUSKESMAS MANIANGPAJO

Alamat Jl. Poros Pare Sengkang, Kecamatan Maniangpajo Kabupaten Wajo 90952
Email : pkmmaniangpajo@yahoo.co.id

PENGKAJIAN GAWAT DARURAT / TINDAKAN

No.RM :

Tanggal : Hari : Jam :

Datang : Ambulance/ Sendiri / Diantar oleh Keluarga / Tetangga / Teman / Polisi

IDENTITAS PASIEN :
TRIASE
1. N a m a : ............................................
2. U m u r : ..................... Laki / Wanita
3. A g a m a : ............................................
4. A l a m a t : ............................................................ Telepon : ........................
IDENTITAS PENGANTAR PASIEN :

1. N a m a : ............................................
2. U m u r : ..................... Laki / Wanita
3. A g a m a : ............................................
4. A l a m a t : ............................................................ Telepon : ........................
ANAMNESE :

1. Keluhan Utama : ...........................................................................

2. Riwayat Penyakit sebelumnya : .................................................................
3. Lainnya : .....................................................................................................

PEMERIKSAAN FISIK :
1. K U : Kesadaran : CM / Apatis / Seporos / Komatus / Koma
T : ...................Mm Hg N : ..................x / mm BB : ..........................
S : ...................OC P : ..................x / mm TB : ..........................

2. Kepala : Mata : Cekung +/-, Conjuktiva Anemis : +/-, Skelera Ikterus +/-
Pupil : Isokor ki dan ka +/- Midriasis / Miosis Ukuran ..........cm
Refleks cahaya ki +/-, ka +/-
Lain-lain : ......................................................................................................

3. L e h e r : JPV. 5 ± : .......................................................................................................
Lain-lain : .......................................................................................................
4. Thorax : - Jantung : Bunyi I dan II Jelas/Tidak, Bunyi Tambahan +/-, Murmur +/-
- Paru : Ronkhi basah halus / kasar / nyaring / tak nyaring
Ronkhi Kering +/-
- Lain-lain : ........................................................................................................

5. Ekstremitas : Sianosis +/-, Clubing +/-, Jari keriput +/- Dingin +/-
Edema +/-, Sendi bengkak +/- di ................................................................
Paraparese +/- Superior / Interior, Hemiparese +/- kiri / kanan

6. Abdomen : Datar / Cekung / Kembung / Lemas / Tegang Nyeri tekan +/-

Defans Muscoler +/-, Turgor Normal / Turun
Belotemen +/-, Bising Usus : ↓ / - / normal / n / ↑ / ↑↑
Hepar tidak teraba / membesar ................................. jpx ..............................jpa
Kenyal / Lunak / Keras / Rata / Tidak Rata Nyeri Tekan +/-
Limpa : ............................................
Ginjal : ............................................
Kandung Kencing : ................................
Lain-lain : ............................................
7. Kemampuan : GCS : E .............................. M : ............................... V : .................................
8. Pemeriksaan Tambahan :
- Laboratorium :
- Lain – lain :

9. Luka – luka

10.Tindakan : .............................................................................................................................

11. Diagnosa Sementara : 1. .......................................................................................................

2. .......................................................................................................
12. Pengobatan :
1. Oksigen .......................... lt / mnt, jam : ......................................
2. Infus .................................. Tetes / menit, jam : ..........................
3. Obat Oral : a. .........................................................................
b. .........................................................................
c. .........................................................................

4. Obat Suntik : a. .........................................................................

b. .........................................................................
c. .........................................................................

13. Keterangan : 1. Dipulangkan / sembuh / belum sembuh

2. Alih Rawatan ke Bagian .......................................................................
3. Alih Rawatan ke Rumah Sakit ..............................................................
Karena tempat penuh / permintaan OS / Kel. Jam .............Tgl.............
4. Alih Rawat Jalan ke Poliklinik Bagian ..................................................
5. Meninggal sesudah dirawat ..................... Jam : ...........Hari :...............
Sebab Kematian : ……………………………..........................................
6. Keluar dari IRD Tgl ………….…. Hari ..................... Jam.....................
Perawat Yang Bertugas, Dokter Yang Bertugas,

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