221695438 resume keperawatan gawat darurat
TRANSCRIPT
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8/18/2019 221695438 Resume Keperawatan Gawat Darurat
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RESUME KEPERAWATAN GAWAT DARURAT
NamaMahasiswa :
Stambuk :
Ruangan :
TanggalPengkajia :
I. IDENTITAS KLIEN
• Nama : No. Reg. : 13 69 89
• Umur : Tgl. MRS :11-07-01
• !e"#$Kelam#" : D#ag"o$a :Trauma %a'#$
• Su(u)*a"g$a :
• Agama :
• +e(er,aa" : +ela,ar
• +e"##(a" : SD
• Alama' : Kom&le($&eru/u"ga"
• +e"a"ggu"g : ra"g 'ua(l#e"
II TRIAGE
• Riwa!atSebelumSakit: +e"2a(#'/era' 2a"g &er"a#er#'a : - /a'-o/a' 2a"g /#a$a#(o"$um$#: a"'#/#o'#%
amo%#4#l#"5&arame45/ore4 Ke/#a$aa"/ero/a' : Ke+u$(e$ma$ Alerg# : -
• R#a2a'+e"2a(#'Se(ara"g
Kelua"u'ama MRS : "2er#&aa/ag#a"(e&ala
Kelua"u'ama$aa'#"# :
(l#e"ma$u(ruma$a(#'e"ga"lu(a&aa/ag#a"(e&alaa"ma'a$e'ela#'
a/ra(ar# mo'or. Tera&a' ema'oma &aa/ag#a"(e&alaa"ma'a
• Ta"a-'a"a #'al5 T* a" **:
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TD : 10)90 mmg
S : 3650; a4#lla
N : 684)m"'5 'era'ur5 lema.
R :
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T) : RL 'e'e$a" %e&a'
L#o%a#"e 1 am&ul
Ke'erola% 1 am&ul)8 ,am)I?
Ra"#'##" 1am&ul)8 ,am)I?
# ANA$ISA DATA
DATA MASA$A%
• DS :
1.
Kl#e"me"gelu"2er#&aa/ag#a"(e
&ala.. I/u Kl#e"me"ga'a(a"a"a(4 #
'a/ra( mo'or a" 'er'ar#( 10 m3. I/u (l#e" me"ga'a(a" 'a(u' a(a"
(eaaa" a"a("2a
• D :
1. Kl#e""am&a(lema
. Kl#e""am&a((e$a(#'a"
mer#"g#$ 3. S(ala"2er# 7-10/era'
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#II REN(ANA TINDAKAN KEPERAWATAN
N' ) TG$ DIAGN'SA DAN
KRITERIA %ASI$
INTER#ENSI RASI
0-06-1
1. N2er#/eru/u"ga"e"ga
" 'rauma (e&ala
• Kr#'er#aa$#l:
N2er##la"g ) /er(ura"g S(ala"2er# 0 TT? "ormal
Kl#e""am&a(r#le($a"'e"
a"g Kl#e""am&a( %er#a
1.
Ka,#'#"g(a'5
lo(a$#a"(ara('er#$'#
("2er#.
/$era$# TT?
3. *er#(a"&o$#$# 2a"g
"2ama"&aa(l#e"
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+,,-#'a
1.1. Me"g(a,#'#"g(a'a"lo(a$#"2er#
a$#l : $(ala"2er# 7-10 /era'
lo(a$#"2er#&aaaera(e&ala.
Me"go/$era$# TT?
a$#l : TD : 10)90 mmgS : 365 0;N : 60 4)#+ : 04)#
3.
Mem/er#(a"&o$#$# 2a"g "2ama"&aa(l#e"a$#l :
(l#e"'e'a&alam&o$#$#'erle"'a"g$elama/er
aa # rua"g'#"a(a"