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  DEPARTEMEN KESEHATAN RI POLITEKNIK KESEHATAN KEMENKES MALANG JURUSAN KEPERAWATAN PROGRAM STUDI D-IV KEPERAWATAN LAWANG  ASUHAN KEPERAWATAN DI RUANG IRD TanggalPengkajian: Pukul: A.   Pengkajian 1.   IdentitasPasien :  Nama : Umur : JenisKelamin : Alamat / No.Telp. : Pekerjaan : Agama : 2.   KeluhanUttama (SaatPengkajian) ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………  3.   RiwayatPenyakitSekarang (termasukmekanisme trauma apabilapasienmengalami trauma) …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………  4.   RiwayatPenyakitDahulu …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………     5.   Usaha Pengobatan yang TelahDilakukan (pre hospital) …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………  6.   AlergiObat ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………  7.   Pengkajian ABCD dan data fokus a)   Airway (JalanNafas) Sekret / muntahan Darah Gurgling Snoring Stridor  b)   Breathing (Pernafasan) Cyanosis P q Penetrating injury Flail chest Sucking chest wound Penggunaan otot bantu pernapasan Pergeseran trakea Suara abnormal pada dada lain-lain, c)   Circulation (Sirkulasi) Hipotensi takikardia takipnea Hipotermia pucat Ekstremitas dingin penurunan capillary refill  penurunan produksi urin lain-lain d)   Disability (Tingkat Kesadaran) GCS : Kesadaran :  e)   Data Fokus    Kulit Inspeksi : Palpasi :    KepaladanLeher Inspeksi : Palpasi : Auskultasi :    Telinga Inspeksi : Palpasi :    Hidung Inspeksi : Palpasi :    RonggaMulutdanTenggorokan Inspeksi : Palpasi : Perkusi : Auskultasi :    Mata Inspeksi :    Toraks Inspeksi : Palpasi : Perkusi : Auskultasi :    Jantung Inspeksi : Palpasi : Perkusi : Auskultasi :     Abdomen Inspeksi : Palpasi : Perkusi : Auskultasi :    Punggung Inspeksi : Palpasi :    Ekstremitas Inspeksi : Palpasi :    AlatKelamin Inspeksi :    Rektum Inspeksi : B.   Assessment (masalah) ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………  C.   Terapi Medis :
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