LAPORAN KEGIATAN DI INSTALASI GAWAT DARURAT

Nama Mahasiswa :
NIM :
RUANGAN :

I. IDENTITAS KLIEN
Nama :
Umur :
Alamat :
Diagnosis Medis :
Diagnosis Keperawatan :
Tanggal Pengkajian :
II. DATA FOKUS

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III. ANALISA DATA

NO DATA PROBLEM ETIOLOGI

IV. RENCANA ASUHAN KEPERAWATAN

a. Tujuan :
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b. Kriteria Evaluasi:
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c. Implementasi:
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d. Evaluasi
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Sampit, …………………………….

Pembimbing praktek Mahasiswa

(………………………………) (…………………………….)

NIP : NIM :
 LAPORAN KASUS INSTALASI GAWAT DARURAT
Nama Mahasiswa :
NIM :
RUANGAN :

A. IDENTITAS KLIEN
Nama :
Umur :
Alamat :
Diagnosis Medis :
Tanggal Pengkajian :

B. PRIMARY SURVEY
1. Airway :

2. Breathing :

3. Circulation :

4. Disability :

5. Exposure :
C. SECONDARY SURVEY

Sign and Symptomp:

Allergies :

Medication:

Past Ilnessess:

Event Preceeding Injury:

D. PEMERIKSAAN FISIK
a. Kepala/Rambut

b. Mata

c. Telinga

d. Hidung

e. Mulut dan Tenggorokan

f. Leher

g. Thorak atau Paru

h. Abdomen

i. Genitalia

j. Ekstrimitas atas

k. Ekstrimitas bawah

l. Data Penunjang Lainnya:

E. ANALISA DATA

NO DATA PROBLEM ETIOLOGI

F. RENCANA ASUHAN KEPERAWATAN

1. Tujuan :
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2. Kriteria Evaluasi:
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3. Perencanaan
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 4. Implementasi
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5. Evaluasi
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Sampit, …………………………….

Pembimbing praktek Mahasiswa

(………………………………) (…………………………….)

NIP : NIM :
Akademi Keperawatan Pemkab Kotim
Jalan Batu Berlian No. 11 Sampit .

TARGET KOMPETENSI
PBK KEPERAWATAN GAWAT DARURAT

NAMA MAHASISWA :
NIM :
PARAF, NAMA PEMBIMBING &
NO TANGGAL
KOMPETENSI KET.
MELIHAT MEMBANTU MANDIRI

1 2 3 4 5 6

1 Melakukan Primary Survey

2 Melakukan Secondary Survey

3 Melakukan pananganan masalah

Airway

4 Melakukan Penanganan masalah

Breathing

5 Melakukan Penanganan masalah

Circulation

6 Melakukan pengkajian tingkat

kesadaran dan GCS

7 Melakukan Triage

8 Melakukan pemasangan gudel

9 Melakukan suctioning

10 Melakukan pemeriksaan EKG

11 Melakukan bebat bidai

12 Melakukan pengambilan darah arteri

13 Memberikan rehidrasi cairan pada

pasien syok

14 Memberikan rehidrasi cairan pada

luka bakar

15 Melakukan RJPO
16 Melakukan pemberian terapi Oksigen
dengan berbagai metode

16 Melakukan Hemlich Manuver

17 Melakukan pengenceran obat obat

emergency

18 Menghitung MAP

19 Menghitung kebutuhan cairan

20 Melakukan Asuhan Keperawatan pada

klien dg kegawatan sistem pernapasan

21 Melakukan Asuhan Keperawatan

Kegawatan pada klien dengan nyeri
dada, IMA, Syok

22 Melakukan Asuhan Keperawatan

Kegawatan pada klien dengan Cedera
Kepala, Kejang, Stroke

23 Melakukan Asuhan Keperawatan

Kegawatan pada klien dengan
gangguan sistem gastrointestinal,
perdarahan saluran cerna, trauma
abdomen

24 Melakukan Asuhan Keperawatan

Kegawatan pada klien dg gangguan
sistem penglihatan

25 Melakukan Asuhan Keperawatan

Kegawatan pada klien dengan
ganggguan sistem perkemihan

26 Melakukan pemasangan tampon

27 Melakukan manajemen keracunan

28 Melakukan asuhan keperawatan

kegawatan obstetric dan ginekologi

29 Melakukan penanganan pada

hipoglikemia

30 Melakukan penanganan pada

hyperglikemia

31 Melatih penanganan pada KAD

32 Melakukan Pemberian pertolongan
pernapasan dengan Ambubag

33 Melakukan Asuhan Keperawatan

Kegawatan sistem pendengaran

34 Melakukan Asuhan Keperawatan

Kegawatan sistem penghidungan

Sampit, 2015
Pembimbing Klinik,

………………………………
NIP