ASUHAN KEPERAWATAN

PADA .. DENGAN DIAGNOSA MEDIS .

DI INSTALASI GAWAT DARURAT (IGD)
RSUP Dr. KARIADI SEMARANG

Disusun untuk Memenuhi Tugas pada Praktik Klinik Stase Gawat Darurat
Pembimbing Klinik

: ...

Pembimbing Akademik : ...

Oleh:
.
.

PROGRAM PROFESI NERS ANGKATAN XXVI

JURUSAN KEPERAWATAN FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
SEMARANG
2015

ASUHAN KEPERAWATAN
Tanggal pengkajian
Tanggal masuk
Ruang

: ............................................. Jam : ............................

: ............................................. Jam : ............................
: IGD

A. Identitas
1. Klien/Pasien
a. Nama (Inisial)
: ....................................................................
b. No. Rekam medik : ....................................................................
c. Umur
: ....................................................................
d. Jenis kelamin
: .....................................................................
e. Agama
: .....................................................................
f. Pendidikan
: .....................................................................
g. Pekerjaan
: .....................................................................
h. Suku
: .....................................................................
i. Bahasa
: .....................................................................
j. Alamat
: .....................................................................
k. Diagnosa Medis : .....................................................................
2. Identitas Penanggung Jawab
a. Nama (Inisial)
: .....
b. Umur
: .
c. Jenis kelamin
: .
d. Alamat
: ..
e. Hubungan dengan klien : ..

B. Pengkajian Primer
1. Airway
....
........................
........................................................................................................................
....

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

....
2. Breathing

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

....

....
3. Circulation:

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

4. Disability:

. .
5. Exposure:

. .
C. Pengkajian Sekunder
1. Anamnesis (SAMPLE)
S (Signs and Symptoms)

A (Allergies)

M (Medications)

.
P (Pertinent Medical History)
..

L (Last Meal)

E (Events)

2. Pemeriksaan Fisik:
Keadaan Umum:

Kesadaran:
.
Vital sign:
TD
: .
HR
: ..
RR
: ..
Suhu
: ..
a. Kepala
Inspeksi:

..........
..................................................................................................................
..................
Palpasi:
..
..........
..................................................................................................................
....................
b. Telinga
Inspeksi:

.
Palpasi:
.
..........
....................
c. Mata
Inspeksi:
.
..........
..................................................................................................................
....................
Palpasi:

..............................
d. Mulut dan Gigi
Inspeksi:
.
..........
..................................................................................................................
...................Palpasi:
.
..........
....................
e. Hidung
Inspeksi:
.
..........
..................................................................................................................
....................
Palpasi:
.
..........
.................
f. Leher:

Inspeksi:

Palpasi:

.............................
g. Dada dan paru
Inspeksi:
.
..........
..................................................................................................................
..................................................................................................................
...................Palpasi:
.
..........
..................................................................................................................
..................
Perkusi:
.
..........
..................................................................................................................
.................
Auskultasi: .
..........
..................................................................................................................
....................
h. Jantung
Inspeksi:
.
..........
..................................................................................................................
....................
Palpasi:
.
..........

..................................................................................................................
....................
Perkusi:
.
..........
..................................................................................................................
.................
Auskultasi:
.
..........
..................................................................................................................
...................
i. Abdomen
Inspeksi:
.
..........
..................................................................................................................
..................
Auskultasi: .
..........
..................................................................................................................
....................Palpasi:
.
..........
..................................................................................................................
....................Perkusi:
.
..........
..................................................................................................................
....................
j. Genetalia
.
..........
......

k. Ekstremitas
Ekstremitas Atas
Kanan:.
....
..........
....
Kiri:.
....
............................................................................................................

................
Ekstremitas Bawah
Kanan:.
........
.......
....
...Kiri:.
..
........

...........................................................................................................
3. Pengkajian Fungsional
a. Oksigenasi
Sebelum sakit:

...

...

..Saat sakit:
..

...
..
...
..

b. Nutrisi dan Cairan

Keterangan
Makan
Frekuensi
Jenis makanan
Minum
Frekuensi
Jenis minuman

Sebelum sakit

Saat sakit

Keterangan:
...

....
c. Eliminasi
BAB
Keterangan
Waktu
Frekuensi
Warna
Konsistensi

Sebelum sakit

Saat sakit

Sebelum sakit

Saat sakit

BAK
Keterangan
Frekuensi
Warna
Jumlah
Keterangan:
.

.
d. Termoregulasi
Sebelum sakit:


....

Saat sakit:

.....
..
e. Psikososial (Stress, Koping, dan Konsep Diri)
Sebelum sakit:

...

...

..
Saat sakit:

..
.

....
f. Rasa Aman dan Nyaman
Sebelum sakit:

...

..

.................................................
Saat sakit:

...

...


...

.
g. Istirahat Tidur
Sebelum sakit:

...

....
Saat sakit:

...

..

D. Pemeriksaan Penunjang
Hari/ Tanggal : ..
Jenis Pemeriksaan

Hasil

Satuan

Nilai Normal

Keterangan

E. Terapi
Jenis Terapi

Dosis

Rute

Indikasi & Cara Kerja

Kontraindikasi

Efek Samping

F. Analisa Data
No

Data

Masalah

Etiologi

Diagnosa

TTD

G. Perencanaan
No

Tgl/Jam

Dx Kep

Intervensi
Tujuan dan Kriteria Hasil

Intervensi

TTD

H. Implementasi
Tgl/ Jam

No. Dx

Implementasi

Respon

TTD

I. Evaluasi
No

Tgl/Jam

Dx Keperawatan

Evaluasi

TTD

J. Pembahasan

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