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Petunjuk Beri tanda ( ) pada kolom yang anda anggap sesuai dengan

kondisi pasien

Tanggal : ................................................. Pukul : ...............................................

I. TRIASE IISI !"E# !$TERKeluhan

Utama

Tanda-tanda

Vital

GCS : E : .......... V: .........M: ........... Pupil :........mm/.......mm Refex

cahaya : ........../.........

T : ............./...........mm!" #adi : .......x/menit $e"ule$/i$$e"ule$

Suhu :.........%C

Pe$na&a'an : ...........x/menit Sp(): ..........*

+,$al : ..............

Statu' +le$"i Tida, a Seut,an :Gan""uan

Pe$ila,u

Tida, te$"an""u +da "an""uan : Tida, memahaya,an

Memahaya,an di$i 'endi$i /

%$an" lain

0ila ada la,u,an Pen",a1ian Re't$ain 2RM/334/3536

Skala %yeri

S,ala 78+CC Untu, ana, 9 tahunPengkajia

n

& ' %ilai

;a1ah Te$'enyum / tida,

e,'p$e'i ,hu'u'

Te$,adan" me$in"i'/

mena$i, di$i

Se$in" men"eta$,an da"u

dan men"atup,an $ahan"Ka,i Ge$a,an #%$mal /

$ela,'a'i

Tida, tenan"/ te"an" Ka,i di uat menendan"/

mena$i, di$i+,ti

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DDDDDDDDDDDDDDDDDDDDDDDDDDD#ama / Tanda Tan"an

%,te$

II. PE%$A+IA% $EPERA,ATA% (DIISI OLEH KEPERAWATAN)5. n&%$ma'i di

dapat

+ut%-+namne'e

!ete$% ?anamne'e #ama :

!uun"an :). Ca$a Ma'u, Falan tanpa antuan Ku$'i R%da Tempat

tidu$ d%$%n"

Falan den"an antuan :@. +'al Ma'u, #%n Ru1u,an Ru1u,an

RiBayat Penya,it

Se,a$an"0e$at

0adan

Tin""i

0adan," cm

RiBayat Penya,it

ahuluRiBayat Pen"%atan

SeelumnyaPen",a1ian #ye$i

5. S,ala #ye$i : .........................................................

). 7$e,uen'i #ye$i : Fa$an" !ilan" timul Te$u'mene$u'

@. 8ama #ye$i : ..........................................................>. Men1ala$ : Tida,

a ....................................................................... Kualita' #ye$i : #ye$i tumpul #ye$i ta1am

Pana' / te$a,a$. 7a,t%$-&a,t%$ pemicu/yan"

mempe$e$at : ..........................................................................................A. 7a,t%$-&a,t%$ yan" men"u$an"i/men"hilan",an

nye$i : ........................................................................Pen",a1ian &un"'i : +,ti

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a Tida, +pa,ah ada $iBayat de,uitu' atau lu,a de,uitu'

a Tida, +pa,ah pa'ien diata' tahun

a Tida,

$-usus Anak

+pa,ah ext$imita' dan adan tida, 'e'uai den"an u'ia pe$,eman"an

a Tida,

+pa,ah 'alah 'atu 1aBaan adalah HaI ma,a la,u,an edu,a'i pence"ahan de,uitu'

Status $e-amilan

Tida, hamil

!amil G$aJida: ................ Pa$a : .............. +%$tu' : ......................

!P!T : ............................

DDDDDDDDDDDDDDDDDDDDDDDDDDD#ama / Tanda Tan"an

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III. PE%$A+IA% *EISPeme$i,'aan d%,te$ Pu,ul :Su1ectiJe

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Peme$i,'aan Penun1an"

EKG : .............................................................................................................

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Radi%l%"i : ................................................................................................................

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8a%$at%$ium : ................................................................................................................

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Peme$i,'aan Penun1an" ia"n%'a

Ke$1a : ...............................................................................................................

...........

ia"n%'a

0andin" : .................................................................................................................

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.........................................Plannin" : Penatala,'anaan/Pen"%atan/Rencana Tinda,an/K%n'ulta'i

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I/. *ASA"A# $EPERA,ATA% A% E/A"0ASI*ASA"A# $EPERA,ATA% E/A"0ASI

Penu$unan ,e'ada$an Ke1an" Ketida,e&e,ti&an / e$'ihan 1alan

na&a'

Se'a, #ye$i Gan""uan hem%dinami, Gan""uan nte"$ita' Kulit Gan""uan Ke'eiman"an cai$an

dan ele,t$%lit Penin",atan 'uhu tuuh 8ain-lain :

/. PE*BERIA% !BAT 1 I%20SPu,ul #ama

(at/n&u'

%'i' Rute ipe$i,'a

(leh

ie$i,an

(leh

/I. TI%A$A%Pu,ul Tinda,an #ama Tanda

Tan"an

/II. $!%ISI PASIE% SAAT PI%A# 1 P0"A% ARI I

Pu,ul : ..............................

Tanda-tanda Vital

GCS : E : .......... V: .........M: ............ T : ............./...........mm!"

#adi : .......x/menit $e"ule$/i$$e"ule$ Suhu :.........%C

Pe$na&a'an : ...........x/menit Sp(): ..........*

Ma'u, $umah 'a,it di $uan" : Petu"a' yan"

mene$ima :Tinda,an lan1utan di : Kama$ (pe$a'i Kama$ 0e$'alin

!

Cath 8a (P

Spe'iali'i$u1u, ,e $umah 'a,it :

ipulan",an pu,ul : Menin""al pu,ul

%+ T$an'p%$ta'i pulan" : Kenda$aan P$iadi +mulan

Kenda$aan FenaLahPendidi,an Ke'ehatan pa'ien pulan" : Ma,an/minum %at te$atu$

Fa"a ,ee$'ihan lu,a

iet :

8ain-lain

#ama / tanda tan"an %,te$ : #ama/tanda tan"an pe$aBat :

/III. 2!""!, 0P Tida, a #ama/tanda tan"an pe$aBat :

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tan""al : .............................

!a'il : .....................................................

................

...............................................................

.................

Petunjuk Beri tanda ( ) pada kolom yang anda anggap sesuai dengan

kondisi pasien

Tanggal : ................................................. Pukul : ...............................................

I. TRIASE IISI !"E# !$TER

KeluhanUtama

Tanda-tanda

Vital

GCS : E : .......... V: .........M: ........... Pupil :........mm/.......mm Refex

cahaya : ........../.........

T : ............./...........mm!" #adi : .......x/menit $e"ule$/i$$e"ule$

Suhu :.........%C

Pe$na&a'an : ...........x/menit Sp(): ..........*

+,$al : ..............Statu' +le$"i Tida, a Seut,an :Gan""uan

Pe$ila,u

Tida, te$"an""u +da "an""uan : Tida, memahaya,an

Memahaya,an di$i 'endi$i /%$an" lain

0ila ada la,u,an Pen",a1ian Re't$ain 2RM/334/3536

Skala %yeri 0%I/ERSA" PAI% ASSESS*E%T

T!!"

Skala ,ong Baker 2A3ES Pain S4aledigunakan untuk pasien de5asa dananak 67 ta-un yang tidak dapat menggamarkan intensitas nyerinya dengan

angka.Instruksikan kepada pasien untuk menunjuk 1 memili- gamar mana

yang paling sesuai dengan yang ia rasakan.,ong Baker 2A3ES

Pain S4ale

Pengkajian %ilai

3 ? 5 San"at aha"ia ,a$ena tida, me$a'a nye$i

'ama 'e,ali) ? @ Sedi,it nye$i> ? Cu,up nye$i

A 8umayan nye$i ? 4 San"at nye$i53 +mat 'an"at nye$i

%umeri4 Rating S4aledigunakan pada pasien de5asa dan anak erusia 6 8ta-un yang dapat menggunakan angka untuk melamangkan angka intensitas

SSESMEN UGD

RSM SITI KHODIJAH

GURAH - KEDIRIRI SE D N PENGK JI N

UNIT G W T D RUR T (UGD)

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nyeri yang dirasakannya.Intruksikan pasien untuk melamangkan nyerinya

dengan angka.%umeri4 Rating S4ale Pengkajian %ilai

3 Tida, nye$i3 ? @ #ye$i $in"an 2'edi,it men""an""u a,ti ? #ye$i 'edan" 2 "an""uan nyata te$hadapa,ti