ASUHAN KEPERAWATAN

PADA .DENGAN DIAGNOSA MEDIS

...
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:
.
.

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 :
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
b. Breathing :
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
c. Circulation :
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
..................................................
d. Disability :
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
.......................................
e. Exposure




..
f. Folley catheter

g. Gastric tube




h. Heart monitor






.
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 :
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
........................................................................
2) Keadaan Fisik
a) Kepala
.....................................................................................................
.....................................................................................................
.....................................................................................................
.........................................................
b) Mata
.....................................................................................................
.....................................................................................................
.....................................................................................................
.........................................................
c) Hidung
.....................................................................................................
.....................................................................................................
.....................................................................................................
.........................................................
d) Telinga
.....................................................................................................
.....................................................................................................
.....................................................................................................
........................................................
e) Mulut
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
f) Leher
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
............................................................................
g) Thorak
Paru-paru
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
Jantung
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
..............................................................................
h) Abdomen
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.................................................................................................
i) Genetalia
.....................................................................................................
.....................................................................................................
.....................................................................................................
....................................................................................................
j) Anus
.....................................................................................................
.....................................................................................................
......................................
k) Ekstremitas
Atas
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
Bawah
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
l) Integumen
.....................................................................................................
.....................................................................................................
.....................................................................................................
.........................................................
 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
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
................................................................
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

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
DAFTAR PUSTAKA