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LAPORAN KASUS

ASUHAN KEPERAWATAN KEGAWATDARURATAN


PADA KLIEN DENGAN .........................................
DI .................. RUMAH SAKIT PHC
SURABAYA
Tanggal .............. s/d ..................

Oleh :
_________________________
NIM ...............................

PROGRAM STUDI PENDIDIKAN PROFESI NERS


SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
TA. 2011/2012

LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN KEGAWATDARURATAN
PADA KLIEN DENGAN .........................................
DI .................. RUMAH SAKIT PHC
SURABAYA
Tanggal .............. s/d ..................

Oleh :
_________________________
NIM ...............................

Mengetahui,

Surabaya, ................ 20.....

Penguji Pendidikan

Penguji Lahan

______________________

______________________

PENGKAJIAN KEPERAWATAN
KEPERAWATAN KEGAWATDARURATAN
STIKES HANG TUAH SURABAYA

Nama mahasiswa
Tgl/jam pengkajian
Tgl/jam MRS
Ruangan

:
:
:
:

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

Nama pasien
Umur pasien
Jenis kelamin
No. RM
Diagnosa medis

:
:
:
:
:

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RIWAYAT KEPERAWATAN
Keluhan Utama ....................................................................................................................................... ..
..................................................................................................................................... ....
...................................................................................................................................
Riwayat
....................................................................................................................................... ..
Kejadian
..................................................................................................................................... ....
................................................................................................................................... ......
................................................................................................................................. ........
............................................................................................................................... ..........
............................................................................................................................. ............
........................................................................................................................... ..............
......................................................................................................................... ................
....................................................................................................................... ..................
.....................................................................................................................
Riwayat
....................................................................................................................................... ..
Penyakit Dahulu ..................................................................................................................................... ....
................................................................................................................................... ......
................................................................................................................................. ........
...............................................................................................................................
Riwayat Alergi
....................................................................................................................................... ..
.....................................................................................................................................
Keadaan Umum O baik
O sedang
O lemah
BB : kg TB : cm
Kesadaran
O compos mentis O delirium O sopor
O somnolen O koma
O alert
O verbal
O pain
O unrespon
GCS : E V M
Vital Sign
Nadi : /menit Suhu : C RR : /menit TD : mmHG
Airway
O paten O obstruksi
Jelaskan : ..................................................................................................................... ...
.................................................................................................................................... .....
..................................................................................................................................
Masalah
....................................................................................................................................... ..
Keperawatan
..................................................................................................................................... ....
...................................................................................................................................
Breathing
Pergerakan dada
: O simetris
O asimetris
Penggunaan otot bantu nafas : O tidak ada O ada
Jelaskan, ...
Suara nafas
: O vesikuler O bronkovesikuler
Suara nafas tambahan
: O tidak ada O ronchi O rales
O stridor

O wheezing
Batuk

Masalah
Keperawatan
Circulation

: O tidak ada O ada,


O produktif O tidak produktif
Keluhan sesak nafas
: O tidak ada O ada
Irama pernafasan
: O reguler
O ireguler
Jelaskan, ...
Alat bantu nafas
: O tidak ada O ada
Jenis : Aliran : lpm
....................................................................................................................................... ..
..................................................................................................................................... ....
...................................................................................................................................
Akral
: O hangat
O kering
O merah
O dingin
O basah
CRT
: O < 2 detik O > 2 detik
Edema

Masalah
Keperawatan
Neurologi

Masalah
Keperawatan
Integumen

Masalah
Keperawatan
Abdomen

: O tidak ada O ada

Irama jantung
: O reguler
O ireguler
Perdarahan
: O tidak ada O ada
Jenis : .
Terpasang CVP : O tidak
O ya
Nilai CVP O normal
O meningkat O menurun
....................................................................................................................................... ..
..................................................................................................................................... ....
...................................................................................................................................
Pupil
: O isokor
O anisokor O reflek cahaya : /
Ukuran pupil
: O normal
O midriasis O pin point
O meiosis
O Lain-lain,
Jelaskan :
Nyeri
: O tidak ada
O ada
P :
Q :
R :
S :
T :
Reflek patologi
: ............................................................................................
.......................................................................................................................................
Gangguan neurologi lain : ............................................................................................
.......................................................................................................................................
....................................................................................................................................... ..
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Luka bakar
: O tidak ada O ada
Presentasi luka bakar :
Turgor kulit
: O baik
O sedang O jelek
Warna mukosa kulit :
Luka dekubitus
: O tidak ada O ada
Grade,

....................................................................................................................................... ..
..................................................................................................................................... ....
...................................................................................................................................
Frekuensi peristaltik usus : O tidak ada O normal O meningkat O menurun
Mual
: O tidak ada O ada
Emesis
: O tidak ada O ada
Gangguan eliminasi
: O tidak ada O ada

Masalah
Keperawatan
Perkemihan

Masalah
Keperawatan
Tindak Lanjut

Jelaskan : .
....................................................................................................................................... ..
..................................................................................................................................... ....
...................................................................................................................................
Terpasang kateter
: O tidak
O ya
Jenis, .
Produksi urin
: O normal
O poliuri O oliguri O anuria (< 100 cc/hari)
Jelaskan
: .
Masalah perkemihan : O tidak ada O ada
Jelaskan
: .
....................................................................................................................................... ..
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O KRS O MRS O PP O DOA O Operasi O Pindah
O Lain-lain,

PEMERIKSAAN PENUNJANG
Jenis pemeriksaan
Jam
Lab / Foto / ECG / Lain-lain

PEMBERIAN TERAPI
Jam
Tindakan / Medikasi

Hasil

Keterangan

PERAWATAN INTENSIF
Jam

TD
RR
HR
Suhu
CVP
SPO2 Input Output Medikasi
(mmHg) (x/menit) (x/menit) (C) (cmH2O) (%)
(cc)
(cc)
obat

TINDAKAN KEPERAWATAN
Waktu

Analisa data dan


Masalah Keperawatan

Tujuan dan
Kriteria Hasil

Tindakan

Evaluasi

RENCANA KEPERAWATAN
No.

Analisa Data
dan Masalah Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN


No.

Waktu
Tgl/jam

Tindakan

TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)

TT