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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 FIKES1Universitas Respati Yogyakarta
(Unriyo)
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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

Program Pendidikan Profesi Ners FIKES2Universitas Respati Yogyakarta

(Unriyo)
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Praktik Klinik Gawat Darurat

D. Riwayat Kesehatan
a. Riwayat Penyakit Sekarang :

b. Riwayat Penyakit Dahulu :

c. Riwayat Penyakit Keluarga :


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(Unriyo)
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Praktik Klinik Gawat Darurat

E. Genogram

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(Unriyo)
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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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(Unriyo)
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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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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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Program Pendidikan Profesi Ners FIKES8Universitas Respati Yogyakarta
(Unriyo)
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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 : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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Program Pendidikan Profesi Ners FIKES9Universitas Respati Yogyakarta
(Unriyo)
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Praktik Klinik Gawat Darurat

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2. Tidur dan istirahat

a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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3. Kenyamanan dan nyeri
a. Sebelum Sakit
DS : .....................................................................................
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Praktik Klinik Gawat Darurat

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b. Selama Sakit
Data Subyektif
Provocatif : ...................................................................
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Paliatif : ...................................................................
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Quality : ...................................................................
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Severity : ...................................................................
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Time : ...................................................................
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Program Pendidikan Profesi Ners FIKES11
Universitas Respati Yogyakarta
(Unriyo)
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Praktik Klinik Gawat Darurat

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DO : .....................................................................................
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4. Nutrisi
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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Program Pendidikan Profesi Ners FIKES12
Universitas Respati Yogyakarta
(Unriyo)
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Praktik Klinik Gawat Darurat

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5. Cairan, Elektrolit dan Asam Basa
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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6. Oksigenasi
a. Sebelum Sakit
DS : .....................................................................................
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Program Pendidikan Profesi Ners FIKES13
Universitas Respati Yogyakarta
(Unriyo)
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Praktik Klinik Gawat Darurat

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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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7. Eliminasi Fekal/Bowel
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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Program Pendidikan Profesi Ners FIKES14
Universitas Respati Yogyakarta
(Unriyo)
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Praktik Klinik Gawat Darurat

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DO : .....................................................................................
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8. Eliminasi urin
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
Program Pendidikan Profesi Ners FIKES15
Universitas Respati Yogyakarta
(Unriyo)
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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 : .....................................................................................
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DO : .....................................................................................
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Program Pendidikan Profesi Ners FIKES16
Universitas Respati Yogyakarta
(Unriyo)
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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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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 :

Program Pendidikan Profesi Ners FIKES18
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(Unriyo)
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c. Cara mengatasinya:




d. Pandangan klien tentang aktifitas sosial dilingkungannya :
.




3. Budaya :
a. Budaya yang diikuti klien adalah:


b. Kebudayaan yang dianut merugikan kesehatannya:




Program Pendidikan Profesi Ners FIKES19
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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 :

Program Pendidikan Profesi Ners FIKES20

Universitas Respati Yogyakarta
(Unriyo)
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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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Universitas Respati Yogyakarta
(Unriyo)
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Praktik Klinik Gawat Darurat

K. Terapi Medis

No Nama Terapi Dosis Fungsi

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Universitas Respati Yogyakarta
(Unriyo)
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Praktik Klinik Gawat Darurat

PRAKTIK GAWAT DARURAT

PRAKTIK
PROGRAM KLINIK KEBUTUHAN
PENDIDIKAN DASAR MANUSIA
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 : Alamat :

TGL/JAM DATA FOKUS ETIOLOGI PROBLEM

Program Pendidikan Profesi Ners FIKES23

Universitas Respati Yogyakarta
(Unriyo)
 PRAKTIK KLINIK KEBUTUHAN DASAR MANUSIA

(Unriyo)
PROGRAM STUDI S-1 ILMU KEPERAWATAN
UNIVERSITAS RESPATI YOGYAKARTA

RENCANA TINDAKAN

Nama klien : No. Register : ..

Umur : Di agnosa Medis :..
Ruang : Al amat : ..

No Diagnosa Keperawatan Tujuan & Kriteria Hasi l Intervensi Rasionalisasi Nama/TTD

Program Pendidikan Profesi Ners FIKES24

Universitas Respati Yogyakarta
Praktik Klinik Gawat Darurat
Buku Panduan Umum
 PRAKTIK KLINIK KEBUTUHAN DASAR MANUSIA

(Unriyo)
PROGRAM STUDI S-1 ILMU KEPERAWATAN
UNIVERSITAS RESPATI YOGYAKARTA

CATATAN PERK EMBANGAN

Nama klien : No. Register : ..

Umur : Di agnosa Medis :..
Ruang : Al amat : ..

No.Dx Tanggal Jam Implement asi Evaluasi Nama/TTD

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