Buku Panduan Umum

Praktik Klinik Gawat Darurat

PRAKTIK GAWAT DARURAT

PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

PENGKAJIAN KEPERAWATAN RUANG ICU

Nama Perawat

: ............................................................................

Tanggal Pengkajian

: ............................................................................

Jam pengkajian

: ............................................................................

A. Biodata :
1. Pasien
Nama

Umur

Agama

Pendidikan

Pekerjaan

Status Pernikahan

Alamat

Tanggal masuk RS

Jam masuk RS

Program Pendidikan Profesi Ners FIKES Universitas

Respati Yogyakarta (Unriyo)
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Buku Panduan Umum

Praktik Klinik Gawat Darurat

Diagnosa Medis

2. Pasien
Nama

Umur

Agama

Pendidikan

Pekerjaan

Status Pernikahan

Alamat

Hubungan dengan klien : ..

B. Alasan Masuk RS

C. Keluhan utama

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Respati Yogyakarta (Unriyo)
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Buku Panduan Umum

Praktik Klinik Gawat Darurat

D. Riwayat Kesehatan
a.

Riwayat Penyakit Sekarang :

b.

Riwayat Penyakit Dahulu :

c.

Riwayat Penyakit Keluarga :

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

E. Genogram

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

F.

Primary Survey
1. Air Way
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2. Breathing
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3. Circulation
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Praktik Klinik Gawat Darurat

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4. Disability
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5. Exposure/Environtment
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G. Secondary Survey
1. Kepala :
a. Kulit

: ................................................................................

b. Rambut

: ................................................................................

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

c. Muka

: ................................................................................

d. Mata

1) Konjungtiva

: ....................................................................

2) Sclera

: ....................................................................

3) Bentuk Pupil

: ....................................................................

4) Ukuran Pupil

: ....................................................................

5) Reflek Pupil

: ....................................................................

6) Palpebra

: ....................................................................

7) Lensa

: ....................................................................

8) Visus

: ....................................................................

2. Hidung

: ................................................................................

3. Mulut

: ................................................................................

4. Gigi

: ................................................................................

5. Bibir

: ................................................................................

6. Telinga

: ................................................................................

7. Leher

: ................................................................................

8. Tenggorokan : .............................................................................
9. Dada

: .............................................................................

a. Pulmo
Inspeksi : .............................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
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Praktik Klinik Gawat Darurat

Auskultasi : ........................................................................
b. Cor
Inspeksi : .............................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
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Auskultasi : ........................................................................
10. Abdomen
Inspeksi : .............................................................................
Auskultasi : ........................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
11. Punggung
Inspeksi : .............................................................................
Palpasi : .............................................................................
12. Genetalia
1) Pria

: .............................................................................
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2) Perempuan : .........................................................................
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Praktik Klinik Gawat Darurat

13. Rectum : ................................................................................

14. Ektremitas
1)

Atas

: .............................................................................
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2) Bawah : .............................................................................
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H. Basic Promoting physiology of Health
1.

Aktivitas dan latihan

a.

Sebelum Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................

b.

Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

DO

: .....................................................................................
.....................................................................................
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Program Pendidikan Profesi Ners FIKES Universitas

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

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2.

Tidur dan istirahat

a. Sebelum Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................

b. Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

DO

: .....................................................................................
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3.

Kenyamanan dan nyeri

a. Sebelum Sakit
DS

: .....................................................................................
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Praktik Klinik Gawat Darurat

b. Selama Sakit
Data Subyektif
Provocatif

: ...................................................................
...................................................................
...................................................................
...................................................................

Paliatif

: ...................................................................
...................................................................
...................................................................
...................................................................

Quality

: ...................................................................
...................................................................
...................................................................
...................................................................

Severity

: ...................................................................
...................................................................
...................................................................
...................................................................

Time

: ...................................................................
...................................................................
...................................................................
...................................................................

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Praktik Klinik Gawat Darurat

DO

: .....................................................................................
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4.

Nutrisi
a. Sebelum Sakit
DS

: .....................................................................................
.....................................................................................
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.....................................................................................

b. Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

DO

: .....................................................................................
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Buku Panduan Umum

Praktik Klinik Gawat Darurat

5.

Cairan, Elektrolit dan Asam Basa

a. Sebelum Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

b. Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

DO

: .....................................................................................
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6.

Oksigenasi
a. Sebelum Sakit
DS

: .....................................................................................
.....................................................................................
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Buku Panduan Umum

Praktik Klinik Gawat Darurat

.....................................................................................
b. Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

DO

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

7.

Eliminasi Fekal/Bowel
a. Sebelum Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

b. Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

.....................................................................................
.....................................................................................
DO

: .....................................................................................
.....................................................................................
.....................................................................................
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8.

Eliminasi urin
a. Sebelum Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

b. Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

DO

: .....................................................................................
.....................................................................................

Program Pendidikan Profesi Ners FIKES Universitas

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

.....................................................................................
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9.

Sensori, persepsi dan kognitif

a. Sebelum Sakit
DS

: .....................................................................................
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.....................................................................................
.....................................................................................

b. Selama Sakit
DS

: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................

DO

: .....................................................................................
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Program Pendidikan Profesi Ners FIKES Universitas

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

I.

Psiko sosio budaya Dan Spiritual

1. Psikologis
a.

Perasaan klien setelah mengalami masalah ini adalah

b.

Cara mengatasi perasaan tersebut

c.

Rencana klien setelah masalah terselesaikan adalah

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Praktik Klinik Gawat Darurat

d.

Jika rencana klien tidak dapat diselesaikan maka :

e.

Pengetahuan klien tentang masalahah/penyakit yang ada :

2. Sosial :
a.

Aktivitas atau peran di masyarakat adalah :

b.

Kebiasaan lingkungan yang tidak disukai adalah :

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Praktik Klinik Gawat Darurat

c.

Cara mengatasinya:

d.

Pandangan klien tentang aktifitas sosial dilingkungannya :

.

3. Budaya :
a.

Budaya yang diikuti klien adalah:

b.

Kebudayaan yang dianut merugikan kesehatannya:

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Praktik Klinik Gawat Darurat

4. Spiritual :
a.

Aktivitas ibadah sehari-hari

b.

Kegiatan keagamaan yang biasa dilakukan

c.

Keyakinan klien tentang peristiwa/masalah kesehatan yang

sekarang sedang dialami :

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Praktik Klinik Gawat Darurat

J.

Pemeriksaan Penunjang
(Hasil pemeriksaan laboratorium,radiology, EKG,EEG dll)
Jenis Pemeriksaan
Hari/Tanggal

NO

:
:

JENIS PEMERIKSAAN

NILAI NORMAL

HASIL

INTERPRETASI

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Praktik Klinik Gawat Darurat

K. Terapi Medis

No

Nama Terapi

Dosis

Fungsi

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Buku Panduan Umum

Praktik Klinik Gawat Darurat

PRAKTIK
GAWAT
DARURAT
PRAKTIK
KLINIK
KEBUTUHAN
DASAR MANUSIA
PROGRAM
PENDIDIKAN
PROFESI NERS
PROGRAM
STUDI
S-1 ILMU KEPERAWATAN
UNIVERSITAS
RESPATI
YOGYAKARTA
UNIVERSITAS RESPATI YOGYAKARTA
ANALISA DATA
Nama klien

: ... No. Register

Umur

: Diagnosa Medis :...

Ruang Rawat :
TGL/JAM

DATA FOKUS

Alamat
ETIOLOGI

:...

:
PROBLEM

Program Pendidikan Profesi Ners FIKES Universitas

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No

Tujuan & Kriteria Hasil

:
:
:

Diagnosa Keperawatan

Nama klien
Umur
Ruang

RENCANA TINDAKAN

Intervensi

No. Register
Diagnosa Medis
Alamat
Rasionalisasi

: ..
:..
: ..

PRAKTIK KLINIK KEBUTUHAN DASAR MANUSIA

PROGRAM STUDI S-1 ILMU KEPERAWATAN
UNIVERSITAS RESPATI YOGYAKARTA

Nama/TTD

Buku Panduan Umum

Praktik Klinik Gawat Darurat

Program Pendidikan Profesi Ners FIKES Universitas

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No.Dx

Tanggal

Nama klien
Umur
Ruang
Jam

:
:
:
Implementasi

No. Register
Diagnosa Medis
Alamat

CATATAN PERK EMBANGAN

Evaluasi

: ..
:..
: ..

PRAKTIK KLINIK KEBUTUHAN DASAR MANUSIA

PROGRAM STUDI S-1 ILMU KEPERAWATAN
UNIVERSITAS RESPATI YOGYAKARTA

Nama/TTD

Buku Panduan Umum

Praktik Klinik Gawat Darurat

Program Pendidikan Profesi Ners FIKES Universitas

25 Respati Yogyakarta (Unriyo)