Flu + batuk

- Obat flu
3x1
- Amok
- Dexa
- Cloramp
3x2
Hypertensi
- Amlodipin
1x1
- Catopril
2x1
- Furosemid
1x1
- Asmet /sanmol 3x1
Hypertensi+jantung
- Ukur kolesterol
- Amlodipin
1x1
- Furosemid
1x1
- Kalium
1x1
Gangguan telinga
- Amok
3x1
- Kotri
2x2
- Analgetik
3x1

Gastritis
Adimag
Omeprazol
Amoxilin

3x1
1x1
3x1

Menstruasi berlebih
Analgetik
3x1
Vit
Obat KB
Nyeri sendi
Alloprinol
3x1
Ibu prof
3x1
Mixalgin
3x1
Dexa
3x1

Asthma
Teopilin
3x1
Ambroksol
Dexa/pred
Amox
Sakit menelan
Sanmol
3x1
Metilpred
3x1
Amok
3x2
Vit
Sariawan
Albotik oles
Amok
3x1
Dexa

Types +demam
Sanmol
3x1
Ibu prop
Kloramp
3x2
Amok
Antasida
Diare/mencret
Obat diare 3x2
Kotri/cipro 2x2
Metro
3x1
Metoklopamid
DM
Mefermin
3x1
Glibenklamid 2x1
Metoklopamid 3x1

Uretritis =kentrik
Cipro
2x1
Kotri
3x1
prednison
3x1
antasida
3x1

Migren/pusing
- Asmet
3x1
- Luminal
1x1
- Vit.
- Antasida
Pusing+lemah
- Paraset
3x1
- Antasida
- Ranitidin
- Vit
1x1
Pusing+nyeri kepala
- Histigo
3x1
- Mixalgin
3x1
- Luminal
1x1
- Antasida
3x1
Nyeri perut + kembung
- Mixalgin
3x1
- Spasminal
3x1
- Ranitidin
2x1
Kolik nyeri pd perut kanan
- Spasminal
3x1
- Omeperazol 2x1
- Ranitidin
3x1
- Natrium dik
Cacar
- Sanmol
3x1
- Sipro
2x1
- Aciklopir
3x1
- Vit.B1
3x1
Keputihan
- metro
3x1
- sipro
2x1
- anti jamur
3x1

BLANKO PENGKAJIAN ASUHAN KEPERAWATAN

KEGAWAT DARURATAN DI RUANG IGD

I.

PENGKAJIAN
A. IDENTITAS
Nama

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

Umur

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

Jenis kelamin : ........................................................

Alamat

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

Suku/Bangsa : .......................................................
Pekerjaan

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

Agama

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

TGL MRS

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

NO RM

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

Diagnosa

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

B. RIWAYAT KEPERAWATAN (NURSING HISTORY)

1. Alasan dirawat /MRS

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

2. Riwayat Penyakit Sekarang

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

3. Riwayat penyakit sebelumnya

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

C. OBSERVASI DAN PEMERIKSAAN FISIK

1. Keadaan umum

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

2. Kesadaran

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

3. Vital sign
S

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

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

RR : ......................
TD : .....................

2. Pemeriksaan Fisik ( body of system )

B1 : BRETHING

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

B2 : BRAIN

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

B3 : BLOOD

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

B4 : BLADDER

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

B5 : BOWEL

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

B6 : BONE

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

D. PEMERIKSAAN PENUNJANG
1. Tanggal pemeriksaan
2. Hasil di Uraikan

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

a. Darah
b. Photo Rontgen
c. CT Scan
d. dll

E. TERAPHY

II.

DIAGNOSA KEPERAWATAN
A. ANALISA DATA

NO

DATA

PENYEBAB

B. RUMUSAN DIAGNOSA KEPERAWATAN

MASALAH

1. ....................................
2. ....................................
3. ....................................
4. DST
III.
NO

INTERVENSI
HR/TGL

TUJUAN DAN KRETERIA HASIL

INTERVENSI

RASIONAL

IV.IMPLEMENTASI
TGL

IV.

DX.KEP

JAM

IMPLEMENTASI

RESPON HASIL

TTD

EVALUASI (CATATAN PERKEMBANGAN/SOAP )

HR/TGL/JAM

NO.DX

SOAP

TTD