Format Laporan Ujian Stase Ugd, HD, Icu
Format Laporan Ujian Stase Ugd, HD, Icu
IDENTITAS PASIEN
PASIEN PENANGGUNG JAWAB PASIEN
Nama :_______________________ Nama :_______________________
Umur :_______________________ Umur :_______________________
Agama :_______________________ Agama :_______________________
Pendidikan :_______________________ Pendidikan :_______________________
Perkerjaan :_______________________ Perkerjaan :_______________________
Status Pernikahan :_______________________ Status Pernikahan :_______________________
Alamat :_______________________ Alamat :_______________________
_______________________ _______________________
_______________________ _______________________
_______________________ _______________________
RIWAYAT KESEHATAN
RIWAYAT KELUARGA
Hipertensi Penyakit pembuluh darah
Diabetes Militus Penyakit gangguan perdarahan
Lain-lain
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
PEMERIKSAAN FISIK
Keadaan Umum
Penampilan Umum
Kesadaran
GCS
Vital Signs TD: mmHg D.Nadi : RR : Suhu :
IMT (indeks masa Tubuh) BB : TB: IMT :
Nyeri/Level nyeri
FokusSistemPerkemihan (Ginjal) :
BB :__________TB:__________TD:_________
b) Ginjal kanandankiri
(1) Massa: Ya,ginjalkanan/ kiri, ukuran____, mobilitas_____ Tidak
(2) Nyeri tekan : Ya, ginjalkanan/ kiri Tidak
c) Vesika urinaria: Penuh Kosong Nyeri tekan
d) Cairan, sirkulasi, elektrolit dan asam basa
1) Intake cairan : oral , _____cc/24 jam IV, _____cc/24 jam
2) Balance cairan : Intake :______________________________=______
Output:_______________________________=______
Balance:_______
3) Turgor : normal jelek. Mukosa: kering lembab
4) Akral : hangat/ dingin, CRT____detik
5) TD_____mmHg, nadi___x/menit, reguler/tidak, kuat/ dangkal, RR___x/menit,
Suhutubuh____JVP ___________ mmHg.
6) Terapidialisis : ya, jenis______tidak; BB pre dialisis :_____BB post
dialisis____IDWG____kg (____%)
7) Edema ekstrimitas : ya , area________________ tidak
8) Perdarahan : ya , area_______jumlah______ tidak
Respirasi
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
Gastrointestinal
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Lain :...................
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Terapi Obat
Jenis Obat Dosis Fungsi
DiagnosaKeperawatan :
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
Intervensi Keperawatan
Tujuan Keperawatan (NOC) Intervensi Keperawatan (NIC)
Diagnosa Kepeawatan
:_______________________________________
_______________________________________
Implementasi
Tindakan Keperawatan Evaluasi Paraf/nama Jam/Tanggal
Pre HD
Proses HD
Post HD
Format laporan ujian stase Elektif ICU
IDENTITAS PASIEN
PASIEN PENANGGUNG JAWAB PASIEN
Nama :_______________________ Nama :_______________________
Umur :_______________________ Umur :_______________________
Agama :_______________________ Agama :_______________________
Pendidikan :_______________________ Pendidikan :_______________________
Perkerjaan :_______________________ Perkerjaan :_______________________
Status Pernikahan :_______________________ Status Pernikahan :_______________________
Alamat :_______________________ Alamat :_______________________
_______________________ _______________________
_______________________ _______________________
_______________________ _______________________
RIWAYAT KESEHATAN
PEMERIKSAAN FISIK
Keadaan Umum
Penampilan Umum
Kesadaran
GCS
Vital Signs TD: mmHg D.Nadi : RR : Suhu :
IMT (indeks masa Tubuh) BB : TB: IMT :
Nyeri/Level nyeri
Respirasi
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
Gastrointestinal
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Urinari
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Ektrimitas
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
_______________
Syaraf
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Lain-lain (endokrin,
reproduksi......)
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Terapi Obat
Jenis Obat Dosis Fungsi
DiagnosaKeperawatan :
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
Intervensi Keperawatan
Tujuan Keperawatan (NOC) Intervensi Keperawatan (NIC)
Diagnosa Kepeawatan
:_______________________________________
_______________________________________
Tujuan Keperawatan (NOC) Intervensi Keperawatan (NIC)
Diagnosa Kepeawatan
:_______________________________________
_______________________________________
Tujuan Keperawatan (NOC) Intervensi Keperawatan (NIC)
Diagnosa Kepeawatan
:_______________________________________
_______________________________________
Implementasi
Tindakan Keperawatan Evaluasi Paraf/nama Jam/Tanggal
Diagnosa Keperawatan :
Tindakan Keperawatan Evaluasi Paraf/nama Jam/Tanggal
Diagnosa Keperawatan :
H 250
E Temp (Biru)
M
O X
D
I
N
A
M 200
I
MAP (Hijau)
K
150
BP (Hitam)
100
HR (Merah)
50
Kesadaran
Irama EKG
Nyeri
CVP
SaO2/SPO2
Pira PEEP/CPAP
si RR
TV
FiO2
N Mata
E Ukuran Pupil
U Reaksi
R Kaki
O Tangan
GCS
M Line 1
S Line 2
K Line 3
Line 4
Enteral
Total
K NGT
E
L Urine
U
BAB
A
Drain
R
Total
Format laporan ujian stase Elektif IGD
IDENTITAS PASIEN
PASIEN PENANGGUNG JAWAB PASIEN
Nama :_______________________ Nama :_______________________
Umur :_______________________ Umur :_______________________
Agama :_______________________ Agama :_______________________
Pendidikan :_______________________ Pendidikan :_______________________
Perkerjaan :_______________________ Perkerjaan :_______________________
Status Pernikahan :_______________________ Status Pernikahan :_______________________
Alamat :_______________________ Alamat :_______________________
_______________________ _______________________
_______________________ _______________________
_______________________ _______________________
RIWAYAT KESEHATAN
INNITIAL ASSESMENT
Airways
Breathing
Circulation
PEMERIKSAAN FISIK
Keadaan Umum
Penampilan Umum
Kesadaran
GCS
Vital Signs TD: mmHg D.Nadi : RR : Suhu :
IMT (indeks masa Tubuh) BB : TB: IMT :
Nyeri/Level nyeri
Respirasi
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
Gastrointestinal
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Urinari
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Ektrimitas
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
_______________
Syaraf
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
Lain-lain (endokrin,
reproduksi......)
Anamnesa :
________________
________________
________________
________________
________________
________________
________________
________________
________________
________________
RIWAYAT KELUARGA
Hipertensi Penyakit pembuluh darah
Diabetes Militus Penyakit gangguan perdarahan
Lain-lain
___________________________________________________________________________________
___________________________________________________________________________________
Terapi Obat
Jenis Obat Dosis Fungsi
Pemeriksaan Penunjang (laboratorium dan diagnostik fokus berkaitan dengan penyakit)
Jenis Pemerikasaan Hasil Keterangan
DiagnosaKeperawatan :
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
Intervensi Keperawatan
Tujuan Keperawatan (NOC) Intervensi Keperawatan (NIC)
Diagnosa Kepeawatan
:_______________________________________
_______________________________________
Tujuan Keperawatan (NOC) Intervensi Keperawatan (NIC)
Diagnosa Kepeawatan
:_______________________________________
_______________________________________