2021

LOG BOOK KGD PRODI STR KEPERAWATAN TANJUNGKARANG

NAMA
MAHASISWA
: NIM
:
LOG BOOK KGD PRODI STR KEPERAWATAN
 LOG BOOK KGD PRODI STR KEPERAWATAN

LOG BOOK KEPERAWATAN

GAWAT DARURAT

Tugas:
1. Baca uraian kasus denga teliti!
2. Lakukan pengelompokan data berdasarkan ABCD kemudian lakukan analisis secara patofisiologi dn
simpulkan masalah keperawatannya untuk masing-masing kasus pada kolom yang disediakan!
3. Rumuskan diagnosis keperawatan utama untuk masiang-masing kasus pada tempat yang disediakan!
4. Susunlah intervensi keperawatan sesuai urutan pelaksanaan tindakan sesuai dengan diagnosis dan
tujuan untuk masing-masing kasus pada kolom yang disedialkan!

KASUS 1
Seorang laki-laki usia 45 tahun diantar ke UGD dengan keluhan sesak nafas berat disertai sianosis. Riwayat kesehatan
pasien menderita asma sejak usia 25 tahun. Hasil pemeriksaan awal: TD: 138/92 mmHg, Nadi: 112 kali/menit, RR: 38
kali/menit, SaO2: 86%, suara nafas whezing dan ronchi basah di seluruh lapang paru.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!
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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 2
Seorang laki-laki usia 35 tahun diantar ke UGD dengan keluhan sesak nafas berat. 30 menit yang lalu mengalami
trauma akibat tertusuk pisau pada dada kanan atas . Hasil pemeriksaan awal: TD: 108/72 mmHg, Nadi: 102 kali/menit,
RR: 32 kali/menit, SaO2: 91%, suara nafas vesikuler pada paru kiri dan tidak terdengar pada paru kanan atas. Pada
perkusi hipersonor pada paru kanan. Terdengar dan terasa udara keluar dari luka tusuk saat inspirasi.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 3
Seorang laki-laki usia 55 tahun diantar ke UGD dengan keluhan nyeri dada. Nyeri dirasakan pada dada kiri seperti
tertimpa benda berat menyebar sampai ke lengan kiri. Pasien mencoba untuk istirahat, tarik nafas dan minum obat
nitorgliserin, tetapi nyeri tidak berkurang. pemeriksaan awal: TD: 82/58 mmHg, Nadi: 122 kali/menit melemah, RR: 24
kali/menit, akral pucat, dingin dan lembab.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer Agen pencedera fisiologis Nyeri akut b.d agen
A: tidak ada hambatan jalan pada pencedera fisiologis
jalan napas
B: s u a r a p e r n a p a s a n Nyeriakut
n o r m a l , RR: 24
kali/menit
C: T D : 8 2 / 5 8
mmHg, Nadi :
122x/menit
melemah, RR : 24
x/menit
D: k e s a d a r a n
composmentis,
GCS 15

Survei sekunder
1. KeluhanUtama : Nyeri dada

2. Riwayat kesehatan
sekarang : pasien mengeluh
Nyeri dirasakan pada dada
kiri seperti tertimpa benda
berat menyebar sampai ke
lengan kiri.

3. Riwayat kesehatan
masalalu : pasien belum
pernah di rawat sebelumnya
dan mengatakan tidak
memiliki penyakit
keturunan

4. Pemeriksaan head to toe

a. Kepala : bentuk kepala
simetris
b. Leher : tidak ada
pembesaran vena
jugularis
c. Thorak : bentuk dada
simetris, tidak ada nyeri
tekan, lapang paru
terdengar sonor, suara
napas vesikuler
d. Abdomen : ada nyeri
tekan, terdengar suara
sonor pada abdomen,
bising usus 7x/menit
e. Integument : tidak
terdapat luka pada kulit
klien
2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

Nyeri akut berhubungan dengan agen pencedera fisiologis

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Pola nafas tidak efektif berhubungan dengan Hambatan upaya napas
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Gangguan rasa nyaman berhubungan dengan gejala
penyakit .............................................................................................................................................................................
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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan

KASUS 4

Ketika pasien sedang dilakukan pertolongan gawat darurat, tiba-tiba pasien mengalami henti jantung henti nafas, nadi
karotis tidak teraba.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan lanjutan!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!
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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 5
Seorang laki-laki usia 32 tahun diantar ke UGD dengan nyeri abdomen. Pasien 30 menit yang lalu kecelakaan lalu
lintas. Tampak jejas memar pada abdomen kanan atas dengan diameter 18 cm, perut membesar (tenderness).
Pemeriksaan awal: TD: 60/- mmHg palpasi, Nadi: nyaris tak teraba, RR: 24 kali/menit, akral pucat, dingin dan lembab,
CRT: 5 detik.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 6
Seorang perempuan usia 19 tahun diantar ke UGD dengan keluhan nyeri perut epigastrik. Riwayat 2 jam lalu minum
racun serangga. Nyeri dirasakan seperti diperas, derajad 8. Pemeriksaan awal: TD: 142/88 mmHg, Nadi: 94 kali/menit,
RR: 22 kali/menit.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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C: ...............................................
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D: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 7
Seorang perempuan usia 58 tahun diantar ke UGD dengan lemas sampai tidak sadarkan diri. Nafas hiperventilasi
(kusmaul). Pasien mempunyai riwayat DM sudah 8 tahun. Pemeriksaan awal: TD: 164/98 mmHg, Nadi: 104 kali/menit,
RR: 29 kali/menit. Cek GDS: 580 mg/dl, AGD: pH: 7,28 , paO2: 94 mmHg, PaCO2: 30 mmHg.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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D: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 8
Seorang laki-laki usia 48 tahun diantar ke UGD dalam keadaan tidak sadarkan diri. Riwayat 1 jam lalu pasien pingsan
saat berolah raga. Pasien adalah penderita DM tipe 1 yang rutin menggunakan insulin. Pemeriksaan awal: TD: 92/60
mmHg, Nadi: 110 kali/menit, RR: 24 kali/menit. Cek GDS: low.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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C: ...............................................
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D: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 9
Seorang laki-laki usia 25 tahun diantar ke UGD dalam keadaan tidak sadar. Riwayat 2 jam lalu kecelakaan lalu lintas..
Pemeriksaan awal: TD: 140/84mmHg, Nadi: 94 kali/menit, RR: 29 kali/menit, GCS: M: 3, V: 2: E: 2, terdengar suara
snoring dan gargling, tampak darah keluar dari hidung telinga dan mulut. Terdapat luka memar dan robek di bagian
kepala frontalis.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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C: ...............................................
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D: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 10
Seorang perempuan usia 42 tahun ditemukan tergeletak di pinggir jalan sambil berteriak minta tolong. Riwayat jatuh
dari motor dan kaki kanannya membentur trotoar. Korban tampak kesakitan pada kaki kanannya dan tidak mampu
menggerakan kaki kanannya. Selanjutnya korban pingsan karena menahan rasa sakit. Suaminya segera menelpon RS
dan 15 menit kemudian ambulan datang dengan seorang perawat. Pemeriksaan awal: kaki kanan tampak bengkok dan
memendek.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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C: ...............................................
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D: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 11
Seorang perempuan usia 60 tahun diantar ke UGD dengan keluhan sesak nafas dan nyeri luka bakar. Riwayat 1 jam lalu
mengalami kecelakaan terbakar akibat ledakan tabung gas. RR: 34 kali/menit, terdengar suara stridor. Tampak luka
bakar derajad 2 dan 3 pada seluruh wajah, seluruh dada dan perut depan, seluruh tangan kanan dan kiri. Hasil
pemeriksaan mukosa mulut dan faring juga terbakar.

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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C: ...............................................
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D: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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.................................................................................................................................................................................
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3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan
KASUS 12
Seorang bayi perempuan usia 3 hari diantar oleh bidan ke UGD dengan sesak nafas berat disertai apneu, sianosis dan
mulai tidak sadarkan diri. Riwayat partus lama dengan ketuban pecah dini. Pemeriksaan awal: tampak letargi
(menurun kesadaran), tampak sianosis, nafas cuping hidung (+), retraksi dada (+), suara nafas stridor di kedua paru,
merintih (+), Pada saat dilakukan pemeriksaan oleh perawat , tiba-tiba bayi mengalami henti jantung dan henti nafas

Tugas:
1. Lakukan analisis data untuk menentukan masalah keperawatan utama!
Data Pathway/Patofisiologi Masalah
Survei primer
A: ...............................................
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B: ...............................................
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C: ...............................................
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D: ...............................................
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Survei sekunder
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....................................................

2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!
Diagnosi Keperawatan Tujuan Intervensi Keperawatan