2021

LOG BOOK KGD PRODI D-III

KEPERAWATAN TANJUNGKARANG

NAMA MAHASISWA:
NIM :
LOG BOOK KGD PRODI D-III KEPERAWATAN 2021
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

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
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

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
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

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
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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan

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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

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
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

KASUS 4
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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

KASUS 5
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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

KASUS 6
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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

KASUS 7
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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D: ...............................................
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Survei sekunder
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2. Rumuskan diagnosis keperawatan utama pasien kasus di atas!

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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

KASUS 8
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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

KASUS 9
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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

KASUS 10
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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 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

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!

................................................................................................................................................................................
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.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
 LOG BOOK KGD PRODI D-III KEPERAWATAN 2021

3. Susun intervensi keperawatan berdasarkan urutan kegiatan yang akan dilakukan!

Diagnosi Keperawatan Tujuan Intervensi Keperawatan