LAPORAN ANALISA KASUS 1. Identitas Klien Nama : ………………………….. Pekerjaan : ………………………….. Umur : ………………………….. No. RM : ………………………….. Alamat : ………………………….. Tgl masuk : ………………………….. Jenis Kelamin : ………………………….. Tgl Pengkajian : ………………………….. 2. Tindakan Pra Hospital a. CPR g. Nasopharingeal airway b. Oksigen h. Suction c. Infus i. Bebat tekan d. NGT j. Bidai e. ETT k.Penjahitan f. Oropharingeal airway l. obat – obatan 3. Triage a. Keluhan Utama : …………………………..…………………………..…………………………..……………………………... b. Riwayat keluhan utama : …………………………..…………………………..………………………….. ………………… …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. c. TTV : …………………………..…………………………..…………………………..…………………………..………………… …………………………..…………………………..…………………………..…………………………..………………………….. d. Berat Badan : …………………………..…………………………..…………………………..…………………………………. 4. Pengkajian primer : Airway : …………………………..…………………………..…………………………..…………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..……………………... Breathing : …………………………..…………………………..…………………………..…………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..……………………... Circulation, : …………………………..…………………………..…………………………..…………………….. …………………………..…………………………..…………………………..…………………………..………………………….. …………………………..…………………………..…………………………..…………………………..…………………………..
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LAPORAN ANALISA KASUS
1. Identitas Klien Nama : ………………………….. Pekerjaan : …………………………..Umur : ………………………….. No. RM : …………………………..Alamat : ………………………….. Tgl masuk : …………………………..Jenis Kelamin : ………………………….. Tgl Pengkajian : …………………………..
2. Tindakan Pra Hospitala. CPR g. Nasopharingeal airwayb. Oksigen h. Suctionc. Infus i. Bebat tekand. NGT j. Bidaie. ETT k.Penjahitanf. Oropharingeal airway l. obat – obatan
3. Triagea. Keluhan Utama : …………………………..…………………………..…………………………..……………………………...b. Riwayat keluhan utama : …………………………..…………………………..…………………………..…………………
…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..
c. TTV : …………………………..…………………………..…………………………..…………………………..……………………………………………..…………………………..…………………………..…………………………..…………………………..
d. Berat Badan : …………………………..…………………………..…………………………..………………………………….4. Pengkajian primer :
Airway : …………………………..…………………………..…………………………..……………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………...
Breathing : …………………………..…………………………..…………………………..……………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………...
Circulation, : …………………………..…………………………..…………………………..……………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………...
Disintegrity) : …………………………..…………………………..…………………………..……………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..
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5. Pengkajian sekunder : Riwayat Penyakit …………………………..…………………………..…………………………..…………………………
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Pemeriksaan Fisik Kepala : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………Mata : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………Telinga : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………Hidung : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………Tenggorokakn : …………………………..…………………………..…………………………..…………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………Leher : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………Dada : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………
Abdomen : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………Ekstremitas : …………………………..…………………………..…………………………..……………………………………………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………
6. Pemeriksaan penunjang : …………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..
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7. Terapi Medikasi :…………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………….………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………….
8. Diagnosa keperawatan : ………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………….………………..………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………….………………..………………………..…………………………..…………………………..…………………………..…………………………..…………………………..……………………………………………………..…………………………..…………………………..………………………………….…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…………………………..…
9. Intervensi KeperawatanNo Diagnosa Tujuan Implementasi Rasional Evaluasi1. ……………………………………….
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