PMH: Sistemik: HTN DM Cancer HIV Thyroid Anemia High lipids Neuro: CVA Seizure J antung: MI Angina CHF CAD Paru: COPD Asthma GI : PUD GERD Liver GU: UTIs Stones MS: Arthritis Psych: Depression Anxiety Schizophrenia None Alasan dirawat: ________________ _____________________________________________ Lainnya __________________________________________________________ ____________ Pengobatan: Tdk Lht Lampiran ________________________________________ ______________________________________________________________________ ______________________________________________________________________ Alergi: Tdk ada Latex __________________________________________________
SUB BAGIAN KGD PSIK FK UGM
Keluhan Utama:
TRIASE: am pm
Datang dgn: Berjalan Kursiroda Teman Dibantu Ambulans Helikopter Polisi Sumber: Pasien Keluarga Teman Perawat perujuk Polisi Waktu: Onset________ Menit Jam Hari Minggu Bulan yll Secara: Tiba-tiba Bertahap Nyeri: Masih Bertambah buruk Berkurang Hilang Lokasi: Kn Kr Umum Frontal Occipital Parietal Temporal Retroorbital Keparahan: Ringan Sedang Parah Riwayat Lainnya:
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PENGKAJIAN KEPERAWATAN: Ruang: am pm Riwayat keperawatan: Review Pengkajian Triase Sumber: Pasien Keluarga Teman Perwata perujuk Polisi Prehospital: RJP Intubasi O2 IV C-collar Backboard Bidai Obat _________Tdk ada Context Circumstances: Spontaneous Recent stress Febrile illness Trauma CO exposure Associated signs and symptoms: None Fever N V Weakness Numbness Photophobia Blurred vision Nasal congestion Lacrimation Aura: Visual Sensory Motor Mood Other history:
Nursing exam: Constitutional: Alert Well-appearing Ill-appearing Confused Poorly responsive Respiratory: R L Bil Wheezes Rales Rhonchi normal CV: Tachycardia Bradycardia Irregular normal Neurologic: Oriented to: Time Person Place Not oriented Unable to test normal Motor function: R L Arm Leg Face Weak Unable to test normal Other exam:
DIAGNOSA KEPERAWATAN: 1. 2. 3.
RENCANA KEPERAWATAN:
KRITERIA HASIL:
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Tanda-tanda Vital Triase S N RR TD
Sat O2 Nyeri Kg
Tingkat Triase
Emergent Urgent Nonurgent
Instruksi, Intervensi, dan Hasil Instruksi yg dijalankan atau intervensi iyg dilakukan Sebelum evaluasi Dokter: Pvt MD notified: YA TIDAK Accucheck ________________ O2: ________________________ IV: ________________________ Monitor ____________________ EKG ________________ XR: _______________________ Labs: _________________________ Test kehamilan urin Pengelolaan pernapasan__________ Splint(s) ____________________ Dressing (s) __________________ Tetanus (lihat form pengobatan) Lainnya: ______________________ Lainnya: ______________________ Hasil Accucheck _________ Repeat _________ Urine Dip SpG _________ Ket _________
INTERVENSI LAINNYA TRAUMA / SURGICAL
C-collar applied ________________
Ortho care ____________________
Ice Elevation
Ace Sling Splint Brace
Shoulder immobilizer Strapping
Knee immobilizer Shoe
Crutch education
Wound care ___________________
Topical anesthesia ____________
Wound prep _________________
Adhesive ___________________
Suturing Staple ____________
Burn care _____________________
Fracture care __________________
I and D _______________________
Arthrocentesis _________________
Chest tube
CARDIOPULMONARY
O2: 4 L NC Mask NRB
Pulse ox: Spot Continuous
Monitor NSR
Rhythm strip __________________
EKG: ED EKG tech
Intubation ____________________
CPR ACLS ___________________
Cardioversion _________________
External pacemaker _____________
CVP placement ________________
Respiratory treatment ___________
Sputum collection ______________
IV Thrombolysis _______________
ABDOMINAL / PELVIC
NG: Size _____ ______________
Gastric lavage: NG Oral
Foley: Size _____ ____________
I and O urine cath ______________
Vomiting management __________
Incontinence management ________
Disimpaction __________________
Enema Type _________________
Sexual assault exam ____________
EYE / ENT
Topical anesthesia ______________
Eye irrigation _____cc of ________
Ear wax/FB removal ___________
Nasal FB removal ______________
Epistaxis control _______________
Laryngoscopy _________________
LAIN-LAIN
Lab draw: ED Lab tech
XR: Patient departed
Patient returned
Injection X 1 2 3 4
Restraints 2 3 4 point
Reassessment _______________
Lumbar puncture Dr. Sim
Blood transfusion ______________
Conscious sedation _____________
Isolation for ___________________ Waktu S N RR TD Sat 02 Nyeri
INSTRUKSI PENGOBATAN DAN IV Waktu
Cairan, Pengobatan Jumlah /Dosis Rute Site
Ukuran
Pump Rate Oleh (Inisial)
Kode Site 1. Deltoid 2. Glutueus 3. Paha anterior 4. Paha lateral 5. Fossa antecubital 6. Lengan 7. Tangan 8. Kaki 9. Leher 10. Intraosseus
DISPOSISI Discharged LWBS AMA Expired Admitted Transferred to: Transfer form completed Mode of departure: Walking Carry Wheelchair Cart Auto Ambulance MediVan _________________________________ Condition on D/C: Pain scale: NA Improved Worsened Good Fair Poor Stable Unstable Critical Verbalizes understanding of discharge instructions Barriers to understanding or learning ___________________________ Written Verbal instructions given to: Report called by: Patient Parent Caregiver ___________________________ Report called to: S Referred to: _______________________PRN / in ________ days D/C ed by: ___________________________