Format Igd STIKES SURYA MITRA HUSADA

FORMAT PENGKA JIAN KEPERAWATAN KEPERAWATAN GAWAT GAWAT DARURAT DAR URAT

   S    A    T    I    T    N    E    D    I

No. Rekam Medis ... ... ...

Diagnosa Medis ... ... ...

Nama

:

Jenis Kelamin : L/P

Umur

:

 Agama

:

Status Perkawinan Perkawinan :

Pendidikan

:

:

Sumer in!ormasi

Alamat

:

Pekerjaan

"anggal Masuk :

TRIAGE

MERAH

:

Jam Datang ke #$D :

P1

KUNIN G

P2

Jam %engkajian %engkaji an :

HIJAU

P3

HITAM

P4

   YGENERAL IMPRESSION    EKelu&an Utama :    V    R.....................................................................................................................................................................    U.....................................................................................................................................................................    S ..................................................................................................................................................................    R    EMekanisme 'edera :    M    I    R.....................................................................................................................................................................    P..................................................................................................................................................................... ..................................................................................................................................................................

$erakan dada: ¨ Simetris

¨ Asimetris

#rama Na!as : ¨ 'e%at

¨ Dangkal

Sesak Na!as : ¨ Ada ) # * ##* ###* # , Pola Na!as

N(' : ¨ Normal ¨ "idak

ada

: ¨ "eratur ¨ "idak "eratur

¨ A%neu

¨ D%snea

¨ (rto%nea

¨ Kussmaul ¨ '&ene

Retraksi otot dada : 'u%ing &idung : Suara Na!as : ¨ Rales

¨ -rad%nea ¨ "a0&i%nea

¨ Ada

¨ Ada

¨ Normal

¨ Ronk&i

stokes

¨ tidak

ada

¨ tidak

ada

N#' :

¨ +&ee1ing ¨ Ronk&i ¨ Krekels

RR : ... ... 2/mnt Kelu&an Lain: ............................................................................................. ............................................................................................. ............................................................................................. ............................................................................................. ............................................................................................. Diagnosa Kepea!a"an#

Diagnosa Kepea!a"an#

DISA*ILITY Res%on

:¨ Alert

Kesadaran: ¨ 'M

¨ eral

¨ Pain

¨ Unres%on

NO, #

¨ Delirium ¨ Somnolen ¨ so%or

¨ Koma

$'S

: ¨ 9e ...

Pu%il

:

¨ eral

...

¨ Motorik

...

¨ #sokor ¨ Unisokor ¨ Pin%oint ¨ Medriasis

Re!leks 'a&aa:

¨ Ada

¨ "idak

Kelum%u&an : ¨ Ada * Lokasi Neri muskul%skeletal :

¨ Ada

Ada ¨ "idak ¨ "idak

Ada

Ada

Kelu&an Lain : ............................................................................................. ............................................................................................. ............................................................................................. ............................................................................................. ............................................................................................. ............................................................................................. ............................................................................................

NI, #

Riwaat Penakit Saat #ni /alasan MRS:

NO, #

............................................................................................. ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ NI, #  Alergi : ¨ (at

¨ Makanan ¨ Lainna

Medikasi seelum diawa ke RS :

Riwaat Penakit Seelumna: ¨ DM ¨ 3" ¨ Jantung ¨ As&ma "a&un : Medikasi :

¨ Paru ¨ Lainna

Makan Minum "erak&ir:

   Y9en/Peristiwa Penea:    E    V    R"anda ital : N:    U-P :

S:

RR :

N(' : ¨ R(N"$9N ¨ '";S'AN ¨ US$ ¨ 9K$ ¨ 9ND(SK(P# ¨ -$A ¨ DL

+asi% # ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ Tin/a)an pengo'a"an # ¨ #n!us

¨ 3ea0ting

¨ Re%osisi

¨ $i%s

¨ "ran!usi

¨ Pemeda&an

¨ Lainna......

Pengo'a"an # ............................................................................................

N#' :

CATATAN PERKEMBANGAN

D78 Kep

+aiTg%$a

Ip%een"asi

TTD

Ea%(asi