KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN

DENPASAR JURUSAN KEPERAWATAN

Alamat : Jl. P MOYO No 33 A , Denpasar Selatan

Telp : (0361) 725273 FAX : (0361) 724568

ASSESSMENT FORMAT
EMERGENCY NURSING

Patient Identity
Name : Mr. T
Age : 34th
Gender : Male
Occupation : Entrepreneurship
Religion : Chirstian
Medical Diagnosis : Vulnus Laserasi + Vulnus Eksoriasi.

Initial survey:
A (alertness) : +
V (verbal) :
P (pain) :
U (unserpons) :

Triage Color : P1 P2 P3 P4 P5
PRIMARY SURVEY AND RESUSITATION

A. AIRWAY AND SERVICAL CONTROL

1. Airway condition
Consciousness level : Compos mentis
Breathing : Breathe spontaneously
Breathe effort : Exist
Foreign body in the airway : No
Breathe blowing : Strong
2. Nursing Diagnosis
-
3. Intervensi / Implementasi
-
4. Evaluation
-

B. BREATHING
1. Breathe Function
Type of respiration : Chest breathing
Respiratory frequency : 20 x/minute
Muscle retraction helps breath : No
Thoracic wall abnormalities : No
Breath sounds : No
Breathe blowing : Strong
B. Nursing Diagnosis
-
C. Intervention / Nursing Implementation
-
D. Nursing Evaluation
-
C. CIRCULATION
1. Circulation State
Level of consciousness : Compos mentis
Bleeding (internal / external) : External, patriarchal exorcation vein and right and
proximal femur laceration vulnus at the left of the
Capillary Refill time : <2 seconds
Blood pressure : 120/80 mmHg
Radial / carotid pulse : Strong
Akral peripheral palpable: Warm

2. Nursing Diagnosis
-Acute pain associated with physical injury agent (blunt trauma) marked with a torn
wound with a depth of ± 0.5cm, the patient looks grimace, the patient appears to hold
the painful part
-The risk of infection is proven by injury torn with ± 0.5cm depth

3. Intervention / Implementation of comprehensive pain assessments

DS:
P = Wound scratched surf board
Q = Feels sore
R = Feels on the injured part, does not spread
S=2
T = Feel when moving
DO: Visible wounds on both knees and left thigh, it is natural for patients to grimace-
Measure vital sign
TD: 120/80 mmHg
Pulse: 84 x / minute
S: 36.4 oC R: 20 x / minute
-Perform wound care
Take care of wounds with NaCl and betadine, k then bandage the wound with sterile
gauze
 1. Evaluation
S: The patient says pain is still felt
P = Surfboard scratches
Q = Feeling sore
R = Feels on the injured part, does not spread
S=2
T = Feel when moving
O: The patient still looks grimace
A: Acute pain has not been resolved
P: Teach non-pharmacological techniques with deep breath relaxation

S: -
O: The wound is well-maintained, there are no signs of infection such as redness,
swelling, fever and changes in function
A: Problems with the risk of infection are resolved
P:
- Give the information about wound care to prevent infection
- Encourage patients to keep wounds dry
- Encourage patients to control health services

C. DISABILITY
A. Neurological examination
GCS : E 4 V 5 M 6 : 15 (Compos Mentis)
555 555
Muscle strengh : 555 555
Pupil : Isokor (+) ᴓ 2mm/ 2mm
Light reflect : +/+
B. Nursing Diagnosis
-
C. Intervention / Nursing Implementation
-
D. Nursing Evaluation
B. EXPOSURE
1. Head to Toe At a glance
a. Head: chepalhematome (-), bleeding (+) in the proximal femur, pain (+)
b. Eyes: anemic - / -, jaundice - / -, pupil reflexes + / +, isocorous
c. Neck: jugular venous distension (-), carotid artery (+), abnormality (-),
enlargement of the thyroid gland (-)
d. ENT: Calm impression
e. Chest: Trace (-), symmetrical chest movement, pulmo: versular + / +,
Ronchi - / -, wheezing - / -, bruising (-)
f. Abdomen: Trace (-), dirt (-), Intestine (+), N: 8x / minute
g. Back: Trace (-), lower back pain (-)
h. Pelvis: Tenderness (-), deformity (-), crepitation (-)
i. Genetalia: Lesions (-), Traces (-), blood (-)
j. Extremities : warm + + ROM 555 555
+ + 555 555

B. Nursing Diagnosis
-
C. Intervention / Nursing Implementation
-
D. Nursing Evaluation
-
 EMERGENCY NURSING CARE
NURSING TOURISM COMMUNITY BEACH
Mr. T WITH VULNUS LACERATUM

BY:
DIV NURSING LEVEL 4 SEMESTER VII

1. Ni Made Whasu Pramesti (P07120215031)

2. Kadek Ayu Nina Lusia Ariandini (P07120215032)
3. Ni Luh Nilam Shanti Cahyani (P07120215033)
4. Ni Wayan Yuskamita Karsaeni (P07120215034)
5. Ni Komang Dini Kesuma Putri (P07120215035)
6. I Gusti Ayu Regita Pramesti Cahyani (P07120215036)
7. I Gede Peri Arista (P07120215037)
8. Ida Ayu Made Utari (P07120215039)

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN DENPASAR
JURUSAN KEPERAWATAN
2018