FORMAT LAPORAN ANALISA SINTESA RUANG RAWAT DARURAT

FORMAT LAPORAN ANALISA SINTESA

RUANG RAWAT DARURAT

Nama Mahasiswa     :............................................       No. BP           :...................................................

Nama Pasien            :............................................       Umur              :...................................................

Diagnosa medis        :............................................       Tanggal          :...................................................

1.        Pengkajian Primer (Airway, Breathing, Circulation, Disability)

A (Airway):

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B (Breathing): ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C (Circulation):

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D (Disability):

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......................................................................................................................................................... E (Exposure):

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2.        Diagnosa Keperawatan (NANDA) (berdasarkan pengkajian primer)

3.        NOC (Nursing Outcomes Classification)

4.        NIC (Nursing Intervention Classification)

5.        Implementasi

6.        Evaluasi (pada pengkajian primer)

7.        Pengakajian Sekunder (pengkajian riwayat kesehatan dan pengkajian head to toe)

Riwayat Kesehatan Sekarang (RKS)

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Riwayat Kesehatan Dahulu (RKD)

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Riwayat Kesehatan Keluarga (RKK)

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Pengkajian Head to toe

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Pemeriksaan Penunjang

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8.        Diagnosa Keperawatan (NANDA) (berdsarkan hasil pengkajian sekunder)

9.        NOC (Nursing Outcomes Classification)

10.    NIC (Nursing Intervention Classification)

11.    Implementasi

12.    Monitoring pasien (/pengkajian berkelanjutan yang dilakukan dan hasil yang didapat)

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13.    Evaluasi hasil akhir (hasil yang didapat saat akhir perawatan)

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14.    Evaluasi diri

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15.    WOC (Web of Caution) Kasus