PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

(INSTALASI RAWAT INTENSIF)

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Hari, Tanggal :

I. Identitas Klien

Nama : No. RM :
Tanggal Lahir : Tanggal masuk RS :
Jenis Kelamin : Tanggal masuk IRI :
Agama : Asal ruang/ RS :
Pendidikan : Tanggal Pengkajian :
Pekerjaan : Sumber Informasi :
Alamat :
Status :
Perkawinan

II. Riwayat Kesehatan

1. Diagnosa Medis
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2. Keluhan Utama dan Alasan Masuk Instalasi Rawat Intensif
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3. Riwayat Penyakit Sekarang
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4. Riwayat Kesehatan Terdahulu :
a. Penyakit yang pernah dialami
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b. Alergi (Obat, Makanan, dll).
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c. Imunisasi
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d. Kebiasaan
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e. Obat-obat yang digunakan
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5. Riwayat Penyakit Keluarga
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GENOGRAM :
III. Pengkajian Keperawatan
1. Tanda vital & nyeri
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2. Pernafasan
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3. Kardiovaskuler
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4. Neurologi dan sensori
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5. Gastrointestinal
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6. Muskuloskeletal & integument
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7. Genito urinary
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8. Risiko keamanan
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9. Aktivitas, istirahat & mobilisasi

Aktivitas harian (Activity Daily Living)

Kemampuan perawatan diri 0 1 2 3 4
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM

Keterangan :
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10. Spiritual
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11. Keadaan Lokal
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IV. Terapi
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V. Pemeriksaan Penunjang
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Pengambil data,
…...……………………….2019

(………………………………..)
NIM.
 ANALISA DATA

NO DATA PENUNJANG MASALAH ETIOLOGI

 ANALISA DATA

NO DATA PENUNJANG MASALAH ETIOLOGI

 RENCANA KEPERAWATAN

NO DIAGNOSA TUJUAN DAN INTERVENSI RASIONAL

KEPERAWATAN KRITERIA HASIL
 RENCANA KEPERAWATAN

NO DIAGNOSA TUJUAN DAN INTERVENSI RASIONAL

KEPERAWATAN KRITERIA HASIL
 RENCANA KEPERAWATAN

NO DIAGNOSA TUJUAN DAN INTERVENSI RASIONAL

KEPERAWATAN KRITERIA HASIL
 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI

 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI