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Lahan

Institusi
Lembar Pencapain Kompetensi Kasus
Kasus TTD Pembimbing
Ruangan Resume Lahan Institusi
Kelolalaan

RUANG UGD

RUANG ICU
 Lembar Pencapain Kompetensi Skill
Tanggal dan Paraf Perawat
Daftar Kompetensi Target 1 2 4 4 5 6 7 8
Sistem Pernapasan
Mengenal tanda-tanda 8
gawat nafas/gagal nafas
Memasang Neck Collar 5
Membebaskan jalan nafas 8
(head tilt, chin lift, jaw trust)
Memasang orofangeal air 5
way, OPA, NPA dan LMA
Menyiapkan dan melakukan 4
inhalasi
Melakukan suction 8
Memberikan nafas buatan
dan bantuan oksigen :
-Bag valve and mask (BVM) 4
-Nasal canul, RM, NRM 5
Memasang threeway 2
Y- connector
Fisioterapi dada 8
Melakukan persiapan 2
pemasangan ventilator
Mampu melakukan
monitoring fungsi
pernafasan :
- AGD interpretasi) 5
- SPO2 (saturasi oksigen) 5
- Menyiapkan 5
Interpretasi foto
rontgen dada/thórax
Melakukan asuhan 2
keperawatan pada klien
dengan ventilator
Sistem Kardiovaskular
Mengenal tanda-tanda henti
jantung dan memberikan
pertolongan:
- RJPO/BHD 1
- Memberikan obat- 4
obatan penanganan
kegawatan
kardiovaskuler
- Mengobservasi tindakan 1
kardioversi
- Mengobservasi dan 4
mengukur CVP
- Melakukan EKG dan 5
iterpretasi EKG
- Mengobservasi arteri 4
line
Memberikan Askep post 2
cardiac arrest
Mengenal tanda-tanda syok 5
kardiogenik dan
hipovolemik
Memberikan Askep pada 5
pasien dengan syok
kardiogenik dan
hipovolemik
Sistem Persarafan
Mengenal tanda-tanda 5
penurunan kesadaran,
mengukur GCS, APVU
Mengetahui tanda-tanda 4
peningkatan TIK
Melakukan Askep pada 4
pasien dengan risiko
peningkatan TIK
Melakukan Askep pada 4
pasien dengan cidera tulang
belakang
Melakukan Askep pada 4
pasien dengan cidera kepala
Sistem Perkemihan
Mengenal tanda-tanda TUR 2
Syndrome
Melakukan spooling post 2
TUR
Memasang khateter urine 5
pada pria
Sistem Pencernaan
Memberikan Askep pada 2
pasien dengan hematemesis
dan melena:
- Melakukan kumbah
lambung
- Memberikan obat-
obatan untuk
menghentikan
perdarahan lambung

Sistem Muskuloskeletal
Mengenal tanda-tanda 5
fraktur
Mengenal tanda-tanda 4
compartemen síndrome
Melakukan pembalutan dan 4
pembidaian
Menyiapkan prosedure 2
pemasangan gips
Melakukan hecting 4
Sistem Integumen
Melakukan pengkajian dan 5
indentifikasi derajat luka
bakar
Memberikan asuhan 5
keperawatan pada klien
dengan luka bakar
- Resusitasi cairan 6
- Perawatan luka 8
bakar

Sistem Endokrin
Mengenal tanda-tanda 4
hiperglikemi
Mengenal tanda-tanda 4
hipoglikemi
Melakukan pemeriksaan 4
gula darah
Mengenal tanda-tanda dan 2
melakukan pertolongan
pada pasien dengan crisis
tyroid
Mengenal tanda-tanda 2
pasien dengan hipertyroid
Keracunan
Mengenal tanda-tanda 4
keracunan dan penyebabnya
Memberikan pertolongan 2
pada keracunan :
- Insectisida
- Narkoba
- Makanan dan
minuman
- Gigitan binatang
berbisa
Melakukan Triage pasien 1
Penanggulangan bencana 1
alam
Panduan Strategi Pelaksanaan dan Strategi Komunikasi Tindakan Keperawatan (SP
dan SK)
LAPORAN STRATEGI PELAKSANAAN DAN STRATEGI KOMUNIKASI
DALAM TINDAKAN KEPERAWATAN (SP dan SK)

Nama Mahasiswa :
NIM :
Tanggal :

A. STRATEGI PELAKSANAAN DALAM TINDAKAN KEPERAWATAN

Identitas Pasien :
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Alasan masuk RS :
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Data fokus :
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Tanda-tanda vital :
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Diagnosa keperawatan :
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Tujuan khusus : tujuan yang akan dicapai dan kriteria hasil
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Tindakan keperawatan : tindakan apa yang akan dilakukan, SOP/checklist tindakan
terlampir
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B. STRATEGI KOMUNIKASI DALAM TINDAKAN KEPERAWATAN

ORIENTASI
 Salam terapeutik :
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 Evaluasi/validasi :
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 Kontrak :
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Topik :
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Waktu :
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Tempat :
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KERJA (langkah-langkah tindakan keperawatan) : komunikasi saat melakukan tindakan

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TERMINASI
 Evaluasi respon klien terhadap tindakan keperawatan
Subjektif :
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Objektif :
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 Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah
dilakukan)
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 Kontrak yang akan datang
Topik :
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Waktu :
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Tempat : …………………………………………………………………………….
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 FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT

A. PENGKAJIAN

No. Rekam Medis ... ... ... Diagnosa Medis ... ... ...
IDENTITAS

Nama : Jenis Kelamin : L/P Umur :

Agama : Status Perkawinan : Pendidikan :
Pekerjaan : Sumber informasi : Alamat :

TRIAGE Merah Kuning Hijau Hitam

GENERAL IMPRESSION
Keluhan Utama :

Mekanisme Cedera :

Orientasi (Tempat, Waktu, dan Orang) :  Baik  Tidak Baik, ... ... ...
AIRWAY
Jalan Nafas :  Paten  Tidak Paten
Obstruksi :  Lidah  Cairan  Benda Asing
Suara Nafas : Snoring Gurgling Stridor N/A
Keluhan Lain: ... ...

BREATHING
Gerakan dada:  Simetris  Asimetris
Irama Nafas :  Cepat  Dangkal  Normal
Pola Nafas :  Teratur  Tidak Teratur
Retraksi otot dada :  Ada  Tidak ada
Sesak Nafas :  Ada  Tidak ada
Frekuensi Nafas : ....................
Keluhan Lain : ....................

CIRCULATION
Nadi :  Teraba  Tidak teraba
Jumlah : x/menit
Sianosis :  Ya  Tidak
CRT :  < 2 detik  > 2 detik
Suara Jantung :  Reguler irreguler
 Jauh normal
Akral : Dingin Hangat
Perdarahan :  Ya  Tidak ada Jumlah..................CC
Keluhan Lain: ....................
 DISABILITY

PRIMARY SURVEY
Respon : Alert  Verbal  Pain  Unrespon
Kesadaran :  CM  Delirium  Somnolen  ... ...
GCS :  Eye ...  Verbal ...  Motorik ...
Jumlah GCS :
Pupil :  Isokor  Unisokor  Pinpoint  Medriasis
Refleks Cahaya:  Ada  Tidak Ada
Lateralisasi :  Ada  Tidak Ada
Keluhan Lain : … …

EXPOSURE
Deformitas :  Ya  Tidak
Contusio :  Ya  Tidak
Abrasi :  Ya  Tidak
Penetrasi :  Ya  Tidak
Burn :  Ya  Tidak
Laserasi :  Ya  Tidak
Swelling :  Ya  Tidak

Keluhan Lain: ....................

ANAMNESA
SECONDARY SURVEY

Riwayat Penyakit Saat Ini : ....................

Riwayat Penyakit Sebelumnya : ....................

Sign and Symptom :

Alergi :

Medikasi :

Past Medical History :

Last Meal/ Makan Minum Terakhir :

Event/ Peristiwa Penyebab :

Tanda-tanda Vital :

BP : mm/Hg N: x/menit S: RR : x/menit SpO2: BB:

Keluhan Nyeri (PQRST)
PEMERIKSAAN FISIK
Kepala dan Leher:
Inspeksi ... ...................................................................................................................................................
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Palpasi ...
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Dada:
Inspeksi ... ... ………………………………………………………………………………………………………...
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Palpasi ... ... ………………………………………………………………………………………………………... .
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Perkusi ... ... ………………………………………………………………………………………………………... .
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Auskultasi ...………………………………………………………………………………………………………... .
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Abdomen:
Inspeksi ... ... ………………………………………………………………………………………………………...
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Palpasi ... ... ………………………………………………………………………………………………………... .
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Perkusi ... ... ………………………………………………………………………………………………………... .
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Auskultasi ... .………………………………………………………………………………………………………...
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Pelvis:
Inspeksi ...
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Palpasi ………………………………………………………………………………………………………............
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Ektremitas Atas/Bawah:
Inspeksi ... ………………………………………………………………………………………………………... .
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Palpasi ... . ………………………………………………………………………………………………………... .
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Punggung :
Inspeksi ... .. ………………………………………………………………………………………………………... .
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Palpasi ...
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Neurologis :
PEMERIKSAAN PENUNJANG
1. Pemerikasaan Lab

2. Pemeriksaan Diagnostik
 RONTGEN  CT-SCAN  USG  EKG
 ENDOSKOPI  Lain-lain, ... ...
Hasil :
 Tanggal Pengkajian : TANDA TANGAN PENGKAJI:
Jam :
Keterangan : NAMA TERANG :

B. ANALISA DATA
NO DATA MASALAH
DS DO KEPERAWATAN
C. DIAGNOSIS KEPERAWATAN
D. RENCANA KEPERAWATAN
N DIAGNOSIS TUJUAN INTERVENSI RASIONAL
O
KEPERAWATAN
E. TINDAKAN KEPERAWATAN
NO DIAGNOSIS TINDAKAN EVALUASI
KEPERAWATAN
F. EVALUASI KEPERAWATAN
NO DIAGNOSIS KEPERAWATAN EVALUASI
 Panduan Pengumpulan Data
PROGRAM ILMU KEPERAWATAN
INSTITUT TEKNOLOGI DAN KESEHATAN BALI
UNIT RAWAT INTENSIVE

Nama Mahasiswa :
NIM :

PENGKAJIAN Nama : ………….............................................................. Penanggung jawab :…………….

KEPERAWATAN Umur : …………………. Thn Jenis Kelamin : L/ P Umur.......................Thn
Agama : Hindu Islam Kristen Budha ………. Jenis Kelamin : L / P
Pendidikan : ………………… Pekerjaan : …………… Alamat :
Alamat : …………………………………………….. ………………………………….....
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Perkawinan : Kawin / Belum Kawin / Lain-lain ………………………………….
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Telp:……………………………
Jam:
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Keluhan Utama MRS:

Keluhan Utama saat pengkajian:

Riwayat penyakit saat ini :

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Riwayat alergi :
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Riwayat pengobatan :
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Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga :

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 PENGKAJIAN DIAGNOSA TINDAKAN
KEPERAWATAN KEPERAWATAN KEPERAWATAN
BREATHING
Airways

Snoring Stridor/crowing
Gurgling Tidak ada
Wheezing Tanda Fraktur Cervikal (ada/tidak ada)
Lain-lain (...........................................................)

Breating (Pola Nafas)

Laju Pernafasan
Dispnea Tachipneu Bradipneu
Orthponeu Apneu Lain-lain (mode ventilator)
RR : …..
Irama Pernafasan
Teratur Tak Teratur Lain-lain (.......................)

PengembanganParu
Simetris Asimetris Lain-lain (.......................)
Flail Chest

Bising pernafasan (auskultasi)

Tidak ada Vesikular Lain-lain (.......................)

Perkusi pernafasan
Sonor Hipersonor Pekak
Lain-lain (.......................)

Penggunaan ototBantu napas

Bahu diangkat Retraksi dada M. Sternocleidomastoideus
Cuping Hidung Pernafasan perut Lain-lain (.......................)

Oksigenasi
Akral dingin Pucat Sianosis

Lain-lain
(………………………...........................................................................................
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BLOOD
Perdarahan
Lokasi : …
Jumlah :…

Pulsasi
Kuat Lemah Tidak teraba

Laju nadi
Takikardia Bradikardia Normal

Ket : …. x/mnt

Tekanan darah
Hipotensi Hipertensi Tidak terukur
 Normal
TD : … mmHg

Nyeri dada
Ada Tidak ada
Lokasi
:…
Karakteristik :
… Jumlah

:…

Perfusi
Akral dingin Pusing/nyeri kepala
Kesemutan Tremor Pucat
Edema
Pengisian kapiler < 3 detik > 3 detik

BRAIN
Kesadaran
 Compos mentis Samnolen Koma
Delirium Apatis

GCS
Eye .... Verbal ... Motorik …

PupilIsokor Anisokor Medriasis

Pinpoint

Reflek Cahaya Ada Tidak ada

Reflek Fisiologis Patella Lain-lain ...

Reflek Patologis Babinzky Kernig

Lain-lain ...

Bicara Koheren Inkoheren

Tidur Malam......jam/hari Siang. . .jam/hari

Ansietas Ada Tidak ada

Lain-lain : (............................................................................................................)
BLADDER

Nyeri pinggang Ada Tidak ada

BAK Lancar Inkontenensia

Anuri

Nyeri BAK Ada Tidak ada

Frekuensi BAK.... Ada Tidak ada

warna...Darah

Kateter Ada Tidak ada

Produksi Urine
AnuriaOliguria
Normal
Urine output : … CC/jam
 BOWEL

TB : ... CM BB: ... Kg

Nafsu makan Baik Menurun
Keluhan Mual Muntah
Sulit menelan

Makan : Frekuensi... x/hari Jumlah :... porsi

Minum : Jumlah ... cc/24 jam

Meteorismus Ada Tidak ada

Acites Ada Tidak ada

BAB Teratur Tidak teratur

Frekuensi BAB : ... x/hari Konsistensi... Warna : darah/lendir

BU (peristaltik usus)......x/mnt

Lain-lain ...

BONE

Nyeri Ada Tidak ada

Problem : ...

Regio : ...

Timing : ...

Kekuatan otot : ...

Kualitas/kuantitas : ...

Skala : ...
Deformitas Ada Tidak ada Lokasi...
Contusio Ada Tidak ada Lokasi...

Abrasi Ada Tidak ada Lokasi...

Penetrasi Ada Tidak ada Lokasi...

Laserasi Ada Tidak ada Lokasi...

Edema Ada Tidak ada Lokasi...

Luka bakar Ada Tidak ada Lokasi...

Grade : ... %
Jika ada luka/vulnus, kaji :

Luas luka : ...

Warna dasar luka :...

Kedalaman : ...

Aktivas dan latihan : 0 1 2 3 4

Makan/minum : 0 1 2 3 4

Mandi : 0 1 2 3 4

Toileting : 0 1 2 3 4

Berpakaian : 0 1 2 3 4

Mobilisasi : 0 1 2 3 4

Berpindah : 0 1 2 3 4

Ambulasi : 0 1 2 3 4

Lain-lain : ....

Keterangan :

0 : Mandiri
1 : Alat bantu
2 : Dibantu orang lain
3 : Dibantu orang lain dan alat
4 : Tergantung total

Keracunan (intoksikasi)

Makanan Gigitan binatang Zat kimia

Gas Obat – obatan Lain-lain (.......................)

Pengkajian Sekunder

Riwayat Kesehatan Sekarang :

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Riwayat Kesehatan Lalu :

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Riwayat Kesehatan Keluarga :
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Pengkajian Head to Toe

Kepala dan wajah

Leher

Thorak
Abdomen dan pinggang

Pelvis dan Perineum

Ekstremitas

Integumen

Pemeriksaan Penunjang & Terapi Medis

Radiologi Laboratorium Darah Pemeriksaan Lain Terapi Medis

Masalah Keperawatan :
1. ……………………………………………………….
2. ……………………………………………………….
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Lembar Presensi Harian Lampiran 14

No Tempat Tanggal Kehadiran Paraf Ket

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