IGD - Refleksi Diskusi Kasus (RDK)

REFLEKSI DISKUSI KASUS

INSTALASI GAWAT DARURAT RSU “NGUDI WALUYO” WLINGI
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WAKTU : TANGGAL ............................................... JAM ......................................

TUJUAN INSTRUKSIONAL UMUM

Peserta memahami tentang refleksi diskusi kasus, serta dapat berperan aktif dan mengikuti
proses RDK pada pasien Nama : ................................................. Tanggal Lahir :............................
Alamat : ...................................................................................................... No. MR : .....................
Prioritas : .........................................................................................................................................
Diagnosa Medis : .............................................................................................................................
Diagnosa Keperawatan : .................................................................................................................

TUJUAN INSTRUKSIONAL KHUSUS

Meningkatnya pengetahuan peserta tentang :

1. Assesmen pasien
2. Intervensi pasien
3. Implementasi pasien
4. Evaluasi pasien

MATERI SBAR

SITUATION :
1. Dokter yang merawat : ........................................................................................................
2. Nama perawat yang bertanggungjawab : ...........................................................................
3. Masalah keperawatan yang belum teratasi : ......................................................................
.............................................................................................................................................
.............................................................................................................................................
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IGD RSUD NGUDI WALUYO WLINGI

IGD - Refleksi Diskusi Kasus (RDK)

BACKGROUND :
1. Kondisi pasien : ...................................................................................................................
.............................................................................................................................................
2. Riwayatalergi : ......................................................................................................................
..............................................................................................................................................
3. Pembedahan : .....................................................................................................................
.............................................................................................................................................
4. Alatinvasive : .......................................................................................................................
5. Obat-obatan : ......................................................................................................................
.............................................................................................................................................
6. Pengetahuan pasien dan keluarga tentang masalah kesehatan : .......................................
.............................................................................................................................................
7. Pemeriksaan diagnostik : ....................................................................................................
.............................................................................................................................................
.............................................................................................................................................
ASSESSMENT :
1. Hasil pengkajian ..................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
2. Tanda vital : .........................................................................................................................
.............................................................................................................................................
3. Pain skore : ..........................................................................................................................
4. Tingkat kesadaran : .............................................................................................................
5. Status restrain : ...................................................................................................................
6. Risiko jatuh : ........................................................................................................................
.............................................................................................................................................
7. Status nutrisi : .....................................................................................................................
8. Eliminasi : ............................................................................................................................
9. Hal-hal yang kritis : ..............................................................................................................
.............................................................................................................................................
.............................................................................................................................................
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IGD RSUD NGUDI WALUYO WLINGI

IGD - Refleksi Diskusi Kasus (RDK)

RECOMMENDATION :
1. Intervensi asuhan keperawatan yang perlu dilanjutkan, termasuk nursing care plan dan
discharge planning : ...........................................................................................................
.............................................................................................................................................
.............................................................................................................................................
2. Edukasi pasien dan keluarganya : .......................................................................................
.............................................................................................................................................
.............................................................................................................................................

METODA

1. Interaksi preseptorsip antara mentor dan presepti

2. Presentasi kasus – Diskusi Pleno/afternoon progress

RENCANA PEMBELAJARAN :

Topik : Refleksi Diskusi Kasus

Metode : Kuliah Singkat
Waktu : 10 menit

KEPALA RUANG IGD PRESEPTOR MAHASISWA

Ns. IDA SUKESI, S.Kep, M.Kep ............................................. ..........................................

NIP. 19691121 199203 2 006

IGD RSUD NGUDI WALUYO WLINGI