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Format Pengkajian

Stase Keperawatan Gawat Darurat dan Kritis

STASE KEPERAWATAN GAWAT DARURAT DAN KRITIS


PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

PENGKAJIAN KEPERAWATAN KRITIS (ICU/ICVCU/ROI/HCU)

Nama Perawat : ............................................................................


Tanggal Pengkajian : ............................................................................
Jam pengkajian : ............................................................................
A. Biodata :
1. Pasien
Nama : ……………………………………………
Tgl Lahir/Umur : …………………………………………...
Agama : ……………………………………………
Pendidikan : ……………………………………………
Pekerjaan : ……………………………………………
Status Pernikahan : ……………………………………………
Alamat : ……………………………………………
……………………………………………
Tanggal masuk RS : …………………………………………
Jam masuk RS : …………………………………………
Diagnosa Medis : …………………………………………
2. Pasien
Nama : ……………………………………………
Umur : ……………………………………………
Agama : ……………………………………………
Pendidikan : ……………………………………………
Pekerjaan : ……………………………………………
Status Pernikahan : ……………………………………………
Alamat : ……………………………………………
……………………………………………
Hubungan dengan klien : …………………………………………..

B. Alasan Masuk RS
……………………………………………………………………………………………………
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Program Pendidikan Profesi Ners 1


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

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C. Keluhan utama
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D. Primary Survey
1. Air Way
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2. Breathing
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Penggunaan ventilator: YA/TIDAK (coret yang tida perlu)
Mode :................................................................
PEEP/CPAP:..........................Tidal Volume:..........................cc
FiO2:............................% I:E Ratio...............................SaO2..................................
RR..................................x/menit

Terapi Oksigen : ..............................................................................

3. Circulation
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Program Pendidikan Profesi Ners 2


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

4. Disability
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5. Exposure/Environtment
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E. Riwayat Kesehatan
a. Riwayat Penyakit Sekarang :
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b. Riwayat Penyakit Dahulu :

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Program Pendidikan Profesi Ners 3


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

.....................................................................................................................................................
.....................................................................................................................................................
c. Riwayat Penyakit Keluarga :
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Program Pendidikan Profesi Ners 4


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

F. Genogram

Keterangan Genogram:

Program Pendidikan Profesi Ners 5


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

G. Secondary Survey
1. Kepala :
a. Kulit : ...........................................................................................................................
b. Rambut : ...........................................................................................................................
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 : ...........................................................................................................................
Auskultasi : ...........................................................................................................................
b. Cor
Inspeksi : ...........................................................................................................................
Palpasi : ...........................................................................................................................
Perkusi : ...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
Auskultasi : ...........................................................................................................................
10. Abdomen
Inspeksi : ...........................................................................................................................

Program Pendidikan Profesi Ners 6


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

Auskultasi : ...........................................................................................................................
Palpasi : ...........................................................................................................................
Perkusi : ...........................................................................................................................
11.Punggung
Inspeksi : ...........................................................................................................................
Palpasi : ...........................................................................................................................
12. Genetalia
1) Pria : ...........................................................................................................................
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2) Perempuan : .......................................................................................................................
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13. Rectum : ...................................................................................................................................
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14. Ektremitas
1) Atas : ...............................................................................................................
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2) Bawah : ...............................................................................................................
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15. Pengkajian 12 nervus cranialis
a. Nervus I
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b. Nervus II
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.
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c. Nervus III
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.
..............................................................................................................................................
.

Program Pendidikan Profesi Ners 7


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

d. Nervus IV
..............................................................................................................................................
.
..............................................................................................................................................
.
e. Nervus V
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.
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.
f. Nervus VI
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.
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.
g. Nervus VII
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.
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.
h. Nervus VIII
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i. Nervus IX
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j. Nervus X
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k. Nervus XI
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.
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.
l. Nervus XII
..............................................................................................................................................
.

Program Pendidikan Profesi Ners 8


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

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

H. Basic Promoting physiology of Health


1. Aktivitas dan latihan
a. Sebelum Sakit
DS : .................................................................................................................................
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b. Selama Sakit
DS : .......................................................................................................................
....................................................................................................................... .....
....................................................................................................................... .....
.................................................................................................................................
DO : ....................................................................................................................... .....
....................................................................................................................... .....
....................................................................................................................... .....
....................................................................................................................... .....
Kemampuan ambulasi & ADL (Indeks Barthel):
Aspek Kriteria Sebelum sakit Selama sakit
Makan/minum 0 : Tidak mampu
1 :Butuh bantuan memotong, menyuap
2 : mandiri
Mandi 0:Tergantug orang lain
1 : Mandiri
Perawatan diri 0 :Membutuhkan bantuan orang lain
(Grooming) 1 : Mandiri dalam perawatan muka, rambut, gigi,
dan bercukur
Berpakaian/berdan 0 : Tergantung
dan orang lain
1 : Sebagian dibantu (misal mengancing baju)
2 : Mandiri
BAK 0 : inkontinensia
atau pakai kateter
dan tidak
terkontrol
1 : Kadang Inkontinensia (maks, 1x24 jam)
2 : Kontinensia (teratur untuk lebih dari 7 hari)
Buang air besar 0 : Inkontinensia (tidak teratur atau perlu
(Bladder) enema)
1: Kadang
Inkontensia (sekali seminggu)
2 : Kontinensia (teratur)
Penggunaan toilet 0 : Tergantung
bantuan orang
lain
1 : Membutuhkanbantuan, tapi dapat melakukan
beberapa hal sendiri
2 : Mandiri
Berpindah 0 : Tidak mampu
1 : Butuh bantuan untuk bisa duduk (2 orang)

Program Pendidikan Profesi Ners 9


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

2 : Bantuan kecil (1orang)


3 :Mandiri
Berjalan/mobilitas 0 : Immobile (tidak mampu)
1 :Menggunakan kursi roda
2 : Berjalan dengan bantuan satu orang
3 : Mandiri (meskipun menggunakan alat bantu
seperti, tongkat)
Naik turun tangga 0 : Tidak mampu
1:Membutuhkan bantuan
1 (alat bantu)
2 : Mandiri

Interpretasi hasil Nilai


Ketergantungan total 0-4
Ketergantungan Berat 5-8
Ketergantungan Sedang 9-11
Ketergantungan ringan 12-19
Mandiri 20

Hasil interpretasi Penilaian pasien: ...........................................................

Program Pendidikan Profesi Ners 10


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

Tabel skala jatuh dari morse :


N Pengkajian Skala Nilai Ket
o
1 Riwayat jatuh : apakah jatuh Tidak 0
dalam 3 bulan terakhir. Ya 25
2 Diagnosa sekunder : Apakah Tidak 0
memiliki lebih dari satu Ya 15
penyakit.
3 Alat Bantu jalan : 0
Bedrest / dibantu perawat
Kruk / tongkat / walker. 15
Berpegangan pada benda – 30
benda sekitar. (Kursi,
lemari,meja).
4 Terapi intravena : Apakah Tidak 0
saat ini terpasang infus. Ya 20
5 Gaya Berjalan / cara 0
Berpindah:
Normal / Besrest / immobile
(tidak dapat bergerak sendiri)
Lemah tidak bertenaga. 10
Gangguan atau tidak 20
normal(pincang /diseret).
6 Status mental: 0
Menyadari kondisi dirinya.
M mengalami keterbatasan 15
daya ingat.
Total nilai

Tingkatan Resiko Nilai MPS


Tidak Beresiko 0 - 24
Resiko Rendah 25 - 50
Resiko Tinggi ≥51

Hasil interpretasi Penilaian pasien: .............................................................

2. Tidur dan istirahat


a. Sebelum Sakit
DS : ..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
.................................................................................................................................
b. Selama Sakit
DS : ..........................................................................................................................
..........................................................................................................................

Program Pendidikan Profesi Ners 11


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

..........................................................................................................................
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DO : ..........................................................................................................................
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3. Kenyamanan dan nyeri
a. Sebelum Sakit
DS : ..........................................................................................................................
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b. Selama Sakit
Data Subyektif
Provocatif : ....................................................................................................
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Paliatif : ....................................................................................................
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Quality : ....................................................................................................
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Region :

Depan Belakang
Severity : ....................................................................................................
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Program Pendidikan Profesi Ners 12


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

....................................................................................................
Time : ....................................................................................................
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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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5. Cairan, Elektrolit dan Asam Basa


a. Sebelum Sakit
DS : .....................................................................................................................
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b. Selama Sakit
DS : .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.................................................................................................................................

Program Pendidikan Profesi Ners 13


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

DO : .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
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Input Output
Makan Urin
Minum Feses
Air IWL
metabolisme
Infus* Drainage*
Nutrisi NGT* Perdarahan*
Obat* Muntah*
Lainnya Lainnya
Total Total
*kalau ada
Balance cairan = Input – Output
= ………………………............................
= ………………………............................

6. Oksigenasi
a. Sebelum Sakit
DS : .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
b. Selama Sakit
DS : .....................................................................................................................
.....................................................................................................................
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.....................................................................................................................
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DO : .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
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7. Eliminasi Fekal/Bowel

Program Pendidikan Profesi Ners 14


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

a. Sebelum Sakit
DS : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
b. Selama Sakit
DS : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
DO : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
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8. Eliminasi urin
a. Sebelum Sakit
DS : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
b. Selama Sakit
DS : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
DO : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
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.......................................................................................................................
9. Sensori, persepsi dan kognitif
a. Sebelum Sakit
DS : .......................................................................................................................
.......................................................................................................................

Program Pendidikan Profesi Ners 15


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

.......................................................................................................................
.......................................................................................................................
b. Selama Sakit
DS : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
DO : .......................................................................................................................
.......................................................................................................................
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I. Psiko sosio budaya Dan Spiritual


1. Psikologis
a. Perasaan klien setelah mengalami masalah ini adalah
……………………………………………………………………………………………
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b. Cara mengatasi perasaan tersebut
……………………………………………………………………………………………
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c. Rencana klien setelah masalah terselesaikan adalah
……………………………………………………………………………………………
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d. Jika rencana klien tidak dapat diselesaikan maka :
……………………………………………………………………………………………
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……………………………………………………………………………………………
……………………………………………………………………………………………
e. Pengetahuan klien tentang masalahah/penyakit yang ada :

Program Pendidikan Profesi Ners 16


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

……………………………………………………………………………………………
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2. Sosial :
a. Aktivitas atau peran di masyarakat adalah :
……………………………………………………………………………………………
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b. Kebiasaan lingkungan yang tidak disukai adalah :
……………………………………………………………………………………………
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c. Cara mengatasinya:
……………………………………………………………………………………………
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d. Pandangan klien tentang aktifitas sosial dilingkungannya :
….
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3. Budaya :
a. Budaya yang diikuti klien adalah:
……………………………………………………………………………………………
b. Kebudayaan yang dianut merugikan kesehatannya:
……………………………………………………………………………………………
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4. Spiritual :
a. Aktivitas ibadah sehari-hari
……………………………………………………………………………………………
……………………………………………………………………………………………

Program Pendidikan Profesi Ners 17


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

……………………………………………………………………………………………
……………………………………………………………………………………………
b. Kegiatan keagamaan yang biasa dilakukan
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c. Keyakinan klien tentang peristiwa/masalah kesehatan yang sekarang sedang dialami :
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………

Program Pendidikan Profesi Ners 18


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

J. Pemeriksaan Penunjang
(Hasil pemeriksaan laboratorium,radiology, EKG,EEG dll)
Jenis Pemeriksaan : ………………
Hari/Tanggal : ………………

NO JENIS PEMERIKSAAN NILAI NORMAL HASIL INTERPRETASI

Program Pendidikan Profesi Ners 19


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

K. Terapi Medis :
Jenis Terapi Nama Obat Dosis Rute Fungsi
Cairan IV

Obat parenteral

Obat peroral

Obat Topikal

STASE KEPERAWATAN GAWAT DARURAT DAN KRITIS


PROGRAM PENDIDIKAN PROFESI NERS
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 20


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

TGL/JAM DATA FOKUS ETIOLOGI PROBLEM

Program Pendidikan Profesi Ners 21


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

Program Pendidikan Profesi Ners 22


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

TGL/JAM DATA FOKUS ETIOLOGI PROBLEM

Program Pendidikan Profesi Ners 23


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

PRIORITAS DIAGNOSA

Program Pendidikan Profesi Ners 24


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

STASE KEPERAWATAN GAWAT DARURAT DAN KRITIS


PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

RENCANA TINDAKAN

Nama klien : …………………………… No. Register : ……………..……..........


Umur : …………………………... Diagnosa Medis : ………………...............
Ruang : …………………………… Alamat : ………………………….

No Diagnosa Tujuan & Kriteria Hasil Intervensi Rasionalisasi Nama


Keperawatan /TTD

Program Pendidikan Profesi Ners 25


Universitas Respati Yogyakarta
Format Pengkajian
Stase Keperawatan Gawat Darurat dan Kritis

STASE KEPERAWATAN GAWAT DARURAT DAN KRITIS


PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

CATATAN PERKEMBANGAN

Nama klien : …………………………… No. Register : …………………..................


Umur : …………………………… Diagnosa Medis: …………………..................
Ruang : …………………………… Alamat : …………………...................

No Tanggal Jam Implementasi Evaluasi Nama/


Dx TTD

Program Pendidikan Profesi Ners 26


Universitas Respati Yogyakarta
Buku Panduan Umum
Praktik Klinik Gawat Darurat

Program Pendidikan Profesi Ners FIKES1Universitas Respati Yogyakarta


(Unriyo)