INTERPRETASI EKG PADA Ny. ....

DI RUANG IGD RSUD KARANGANYAR

1. IDENTITAS PASIEN
a. Nama : ..................................................................
b. No RM : ..................................................................
c. Hari / tanggal pemeriksaan : ..........................................................
d. Jam pemeriksaan : ..................................................................
e. Diagnosa medis : ..................................................................

2. HASIL INTERPRETASI EKG

a. Irama : ................................................................
b. Frekuensi : ................................................................
c. Gelombang P : ................................................................
d. Interval PR : ................................................................
e. Kompleks QRS : ................................................................
f. Gelombang T : ................................................................
g. Gelombang U : ................................................................
h. Interval QT : ................................................................
i. Segmen ST : ................................................................
j. Axis : ................................................................

3. KESIMPULAN DAN PEMBAHASAN

a. Kesan / kesimpulan :
..........................................................................................................
..........................................................................................................

b. Analisa kasus / hasil interpretasi EKG :

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

Mahasiswa Praktikan Mengetahui

Pembimbing klinik (CI )

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 INTERPRETASI ASAM BASA
( Data Soal )

1. IDENTITAS PASIEN
a. Nama : No Name
b. No RM :
c. Hari / tanggal pemeriksaan :
d. Jam pemeriksaan :
e. Diagnosa medis :

2. HASIL INTERPRETASI ASAM BASA

a. PH : 7,30
b. PCO2 : 47
c. HCO3 : 23

3. KESIMPULAN DAN PEMBAHASAN

a. Kesan / kesimpulan :

NILAI NORMAL
PH : 7,30 Menunjukkan PH : 7,35-7,45
Asidosis
PCO2 : 47 Menunjukkan PCO2 : 35-45
Hipoventilasi alveolar
HCO3 : 23 Menunjukkan HCO3 : 22-26
normal

b. Analisa kasus / hasil interpretasi ASAM BASA :

Asidosis Respiratorik

Mahasiswa Praktikan Mengetahui

Pembimbing Akademik

.................................. ..................................
A. HASIL TRIANGE :
Merah / Kuning / Hijau / Hitam
C. Pengkajian Primer ( Primary Survey )
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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D. Pengkajian Sekunder ( Secundary survey )

1. Full set of vital sign (F)
Tanda- tanda vital :
a. Tekanan darah : ............... mmHg
b. Nadi :
Frekuensi : ............... x/menit
Irama : ..............................
Kekuatan : ..............................
c. Respirasi :
Frekuensi : ............... x/menit
Irama : ..............................
d. Suhu : ............... C
e. Keadaran : ..............................
f. Keadaan umum : ..............................
2. Five Intervention
Pengkajian Nyeri :
a. Pemasangan EKG : ( ya/tidak ), hasil :
 b. Pemasangan NGT : ( ya/tidak ), hasil :
c. Pemasangan Folley chateter : ( ya/tidak ), hasil :
d. Pengambilan darah untuk cek Lab / pemeriksaan Radiologi bila
curiga fraktur : ( ya/tidak ), hasil :
e. Pemasnagan pulse oximetry : ( ya/tidak ), hasil :
3. Give comfort
Pengkajian Nyeri :
P : ......................................................................................................
Q : ......................................................................................................
R : ......................................................................................................
S : ......................................................................................................
T : ......................................................................................................

4. History ( SAMPLE )
S: ...............................................................................................
...............................................................................................
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A: ...............................................................................................
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M: ...............................................................................................
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P : ...............................................................................................
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L: ...............................................................................................
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E : ...............................................................................................
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5. Head to Toe
1) Bentuk Kepala: ....................................................................
2) Kulit kepala : ....................................................................
3) Rambut : ....................................................................
4) Wajah :
a) Muka : .............................................
b) Mata : .............................................
c) Palbebra : .............................................
d) Konjungtiva : .............................................
e) Sclera : .............................................
f) Pupil : .............................................
g) Diameter ka/ki : .............................................
h) Reflek cahaya : .............................................
i) Alat bantu penglihatan : .............................................
j) Hidung : .............................................
k) Mulut : .............................................
l) Gigi : .............................................
m) Telinga : .............................................

5) Leher : ....................................................................

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6) Dada
a. Paru-paru
I : ....................................................................................
P : ....................................................................................
P : ....................................................................................
A: ....................................................................................
b. Jantung
I : ....................................................................................
P : ....................................................................................
P : ....................................................................................
 A: ....................................................................................
7) Abdoment
I : ....................................................................................
P : ....................................................................................
P : ....................................................................................
A: ....................................................................................
8) Genetalia
9) Rektum
10) Ekstremitas
a) Atas
Kekuatan otot ka/ki : .........................................
ROM ka/ki : .........................................
Capilary Refill Time ka/ki : .........................................
Perubahan bentuk tulang : .........................................
b) Bawah
Kekuatan otot ka/ki : .........................................
ROM ka/ki : .........................................
Capilary Refill Time ka/ki:........................................
Perubahan bentuk tulang : ........................................

E. Riwayat kesehatan keluarga :

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F. Pemeriksaan Laboratorium dan data Penunjang
Tanggal/Jam Jenis Pemeriksaan Hasil Satuan Nilai Ket
Normal .
Hemoglobin g/dl 14.0-17.5
Hematokrit % 40-52
Lekosit 103/ul 4.4-11.3
Trombosit 103/ul 136-380
Eritrosit 106/ul 4.5-5.9
MPV Fl 6.5-12.00
PDW Fl 9.0-17.0
MCV Pg 82.0-92.0
MCH g/dl 28-33
MCHC % 32.0-37.0
Neutrofil% % 5.0-7.00
Limfosit% % 25.0-40.0
Monosit% % 3.0-9.0
Eosinofil% % 0.5-5.0
Basofil% 103/ul 0.0-1.0
Neutrofil# 2,00-7,00
103/ul
Limfosit# 1.25-4.0
103/ul
Monosit# 0.30-1.00
103/ul
Eosinofil# 0.02-0.50
103/ul
Basofil# 0.0-10.0
%
RDW 11-16
Fl
RDW-SD
GDS 70-150
Mg/100ml
Creatinin < 1.0
Mg/100ml
Ureum 31-50
Mg/dl
EKG
 G. Terapi Medis
Golongan & Fungsi &
Tanggal Jenis Terapi Dosis
Kandungan Farmakodinamik
4. ANALISA DATA
Nama : ......................... No CM : .........................
Umur : ......................... Th Diagnosa medis : ......................
Hari / tgl /
Data Fokus Problem Etiologi Symptom
jam

Prioritas diagnosa keperawatan :

1. ................................................................................................................
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2. ................................................................................................................
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3. ................................................................................................................
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5. PRIORITAS DIAGNOSA

6. INTERVENSI KEPERAWATAN

Hari No Tujuan dan Kriteria Hasil Intervensi

/Tgl Dx

7. IMPLEMENTASI KEPERAWATAN
Hari
Tgl No Implementasi Respon TTD
Jam DX
8. EVALUASI
No DX Hari/tgl/jam Evaluasi T
T
D