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ASUHAN KEPERAWATAN

PADA .DENGAN DIAGNOSA MEDIS


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DI INSTALANSI GAWAT DARURAT (IGD) RSUP DR.KARIADI
SEMARANG
Disusun untuk Memenuhi Tugas pada Praktik Klinik Stase Gawat Darurat
Pembimbing Klinik : ...
Pembimbing Akademik : ...
Pembimbing Akademik : ...

Oleh:
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PROGRAM PROFESI NERS

DEPARTEMEN ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN

UNIVERSITAS DIPONEGORO

SEMARANG
2017
ASUHAN KEPERAWATAN GAWAT DARURAT

PADA .......................... DI INSTALASI GAWAT DARURAT (IGD)

RSUP DR. KARIADI SEMARANG

A. PENGKAJIAN
Dilakukan pada tanggal: ................................... Pukul: ......................................
1. Identitas Pasien
Nama : .................................................................................
Umur : .................................................................................
Jenis kelamin : .................................................................................
Agama : ................................................................................
Status : .................................................................................
Pekerjaan : ..................................................................................
Alamat : .................................................................................
Pendidikan : .................................................................................
Suku/Bangsa : ..................................................................................
Tanggal masuk RS : ...................................... Pukul: ...............................
No. RM : .................................................................................
Diagnosa medis : ..................................................................................
2. Identitas Penanggung Jawab Pasien
Nama : .................................................................................
Umur : ..................................................................................
Jenis kelamin : .................................................................................
Hubungan : .................................................................................
Alamat : ..................................................................................
No. Telepon : .................................................................................
3. Pengkajian Primer
a. Airway :
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b. Breathing :
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c. Circulation :
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d. Disability :
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e. Exposure




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f. Folley catheter


g. Gastric tube




h. Heart monitor






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4. Pengkajian Sekunder
a. Pengkajian SAMPLE
1) Symptom





2) Allergy

3) Medication

4) Past Illnes

5) Last Meal






6) Event

b. Pemeriksaan Fisik
1) TTV saat pengkajian :
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2) Keadaan Fisik
a) Kepala
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b) Mata
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c) Hidung
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d) Telinga
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e) Mulut
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f) Leher
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g) Thorak
Paru-paru
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Jantung
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h) Abdomen
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i) Genetalia
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j) Anus
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k) Ekstremitas
Atas
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Bawah
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l) Integumen
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5. Pemeriksaan Penunjang
Jenis Pemeriksaan Hasil Nilai Normal Interpretasi
6. Terapi Medis

Jenis Terapi Indikasi Kontraindikasi Efek Samping


B. ANALISA DATA
No Data Problem Etiologi
C. PRIORITAS DIAGNOSA KEPERAWATAN
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D. INTERVENSI
Tgl/jam Dx.Kep Tujuan&Kriteria Hasil Intervensi
E. IMPLEMENTASI
Tgl/jam No. Dx. Kep Implementasi Respon pasien Paraf
F. EVALUASI
Tgl/jam Dx. Kep Evaluasi Paraf
PEMBAHASAN

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DAFTAR PUSTAKA