LAPORAN PENDAHULUAN KASUS KRITIS (ICU)

A. Gambaran Kasus
1. Definisi
DHF (Dengue Haemorrhagik Fever) adalah suatu infeksi arbovirus akut yang masuk ke dalam
tubuh melalui gigitan nyamuk aedes aegepty. Penyakit ini sering menyerang anak, remaja, dan
dewasa yang ditandai oleh panas, malaise, sakit kepala, mual, nyeri, pegal seluruh tubuh, adanya
petekia (Suriadi & Yuliana, 2006).
DHF (Dengue Haemorrhagik Fever) adalah penyakit demam yang disebabkan oleh virus disertai
demam akut, perdarahan, tedensisyok (Suryanah, 1996)

2. Gambaran Klinis (pengkajian)

a. Tanda & Gejala Umum
1. Panas berlangsung 2-7 hari
2. Malaise, mual, muntah, diare, konstipasi, sakit kepala, anoreksia, kadang batuk
3. Tanda perdarahan seperti petekia, perdarahan gusi, epitasis, hematemesis melena
4. Muka kemerahan, leukopenia
5. Nyeri otot, tulang sendi abdomen dan ulu hati
6. Pembengkakan sekitar mata
7. Tanda rejatan adalah sianosis, kulit lembab dan dingin, tekanan darah menurun
(Menurut Khair, 2013)

b. Tanda & Gejala Kegawatdaruratan (ABCD)

1) Airway (A)
Tidak ada sumbatan jalan nafas maupun lidah.

2) Breathing (B)
Sesak, ada tidaknya otot bantu nafas, suara nafas, Respirasi > 24x/menit

3) Ciculation (C)
Nadi teraba lemah, Nadi tidak teratur, CRT >2detik, akral dingin, dan tidak terdapat
sianosis, kulit lembab, output urine menurun, perdarahan: petekia, perdarahan gusi,
hematemesis melena

4) Disablity (D)
Kesadaran compomentis, GCS 15 E: 4 V:5 M:6

c. Tes Diagnostik (pemeriksaan penunjang)

1. IgG dengue positif
2. Trombositopenia
3. Hematocrit meningkat lebih dari 20 merupakan indicator akan timbul rejatan
4. HB meningkat >20%
5. Leukopenia pada hari 2 dan 3
6. Urine albuminuria
7. Foto thorax: efusi pleura

3. Patofisiologi / Pathway (Gambar/Bagan)B. Diagnosis Keperawatan / Masalah Keperawatan

1. Pola nafas tidak efetif berhubungan dengan efusi pleura.
2. Deficit volume cairan berhubungan dengan kekurangan intake cairan
 3. Resiko terjadi perdarahan berhubungan dengan factor pembekuan darah
(trombositopeni)

C. Perencanaan Keperawatan
1. Pola nafas tidak efetif berhubungan dengan efusi pleura.
Intervensi:
a. Kaji frekuensi dan kedalaman pernafasan
b. Auskultasi bunyi nafas dan suara nafas tambahan
c. Berikan posisi semi-fowler
d. Berikan terapi oksigen
2. Deficit volume cairan berhubungan dengan kekurangan intake cairan
Intervensi:
a. Observasi tanda-tanda vital
b. Monitor tanda-tanda kekurangan cairan
c. Observasi intake dan output cairan
d. Monitor nilai Lab
e. Kolaborasi pemberian cairan intravena
3. Resiko terjadi perdarahan berhubungan dengan factor pembekuan darah (trombositopeni)
Intervensi:
a. Observasi tanda-tanda vital
b. Observasi tanda-tanda perdarahan
c. Monitor tanda-tanda penurunan trombosit
d. Anjurkan klien untuk banyak istirahat
e. Beri penjelasan kepada klien dan keluarga untuk melaporkan jika ada tanda
perdarahan

D. Daftar Rujukan/Referensi:
Donges, Marillyn E. 1999. Rencana asuhan keperawatan. Edisi 3 Jakarta: EGC
Nanda. 2015. Diagnosis keperawatan definisi dan klasifikasi 2015-2017. Edisi 10 Editor: T
Heather Herdman, Shiqemi Komitsura. Jakarta: EGC
PPNI . 2017. Standar diagnosis Keperawatan Indonesia Definisi dan Indikator Diagnosis Edisi
2: Jakarta . DPP PPNI
Suriadi, Rita Yuliani. 2006. Asuhan keperawatan pada anak. Edisi 2 Jakarta: Sagang Setia
 LAPORAN ASUHAN KEPERAWATAN RITIS (ICU)

A. Identitas Pasien
Nama : An. A (inisial) Tanggal masuk ICU : 3 April 2019
Umur : 6 tahun Pukul : 22.45 WIB
Jenis kelamin : Laki-laki

B. Keluhan utama
Sesak
Klien mengeluh sesak saat datang di ruang ICU. Sesak bertambah ketika berbaring dan
berkurang saat duduk, sesak dirasakan hilang timbul pada daerah dada. RR: 50x/menit
C. Riwayat penyakit sekarang
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D. Riwayat Penyakit Dahulu

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E. Pengkajian Primer
1) Airway (A):
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2) Breathing (B):
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3) Circulation (C):
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4) Disability
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F. Pengkajian Sekunder
Keadaan Umum dan Tanda-tanda Vital:
Kesadaran ........................................ GCS: ........................, TD: ............... mmHg, Nadi: .........
kali/menit, RR: ........... kali/menit, suhu: ......... o C, Nyeri: ........................................................,
SaO2: ......................

Pengkajian
Kebutuhan Kebutuhan Dasar
Oksigen

Kebutuhan
Cairan &
Elektrolit

Kebutuhan
Nutrisi &
Metabolik
 Kebutuhan
Aman &
Nyaman

Kebutuhan
Eliminasi

Kebutuhan
Aktivitas &
Istirahat

Pemeriksaan Penunjang & Terapi Medis Terkini

Radiologi Laboratorium Darah Terapi Medis

G. Analisis Data
Data Pathway/Patofisiologi Masalah
H. Masalah / Diagnosis Keperawatan
1. ............................................................................................................................................................
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2. ............................................................................................................................................................
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3. ............................................................................................................................................................
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I. Perencanaan Keperawatan
Diagnosis Keperawatan Tujuan Intervensi Keperawatan
Lanjutan
 Diagnosis Keperawatan Tujuan Intervensi Keperawatan

J. Pelaksanaan dan Evaluasi Keperawatan

 Tanggal & Jam Implementasi Paraf & Nama Evaluasi (SOAP)

Lanjutan ...
 Tanggal & Jam Implementasi Paraf & Nama Evaluasi (SOAP)

Lanjutan ...
Tanggal & Jam Implementasi Paraf & Nama Evaluasi (SOAP)

Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Data Masalah
Survey 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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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf
S: .................................
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Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 13
 RESUME ASUHAN KEPERAWATAN
Identitas Pasien
Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Data Masalah Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf

Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 14
 Survey primer: S: .................................
A: ................................. .................................
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Survei sekunder: .................................
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RESUME ASUHAN KEPERAWATAN

Identitas Pasien
Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Data Masalah Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 15
 Survey primer: S: .................................
A: ................................. .................................
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Survei sekunder: .................................
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RESUME ASUHAN KEPERAWATAN

Identitas Pasien
Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Data Masalah Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 16
 Survey primer: S: .................................
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Survei sekunder: .................................
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RESUME ASUHAN KEPERAWATAN

Identitas Pasien
Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Data Masalah Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 17
 Survey primer: S: .................................
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Survei sekunder: .................................
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RESUME ASUHAN KEPERAWATAN

Identitas Pasien
Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Data Masalah Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 18
 Survey primer: S: .................................
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Survei sekunder: .................................
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RESUME ASUHAN KEPERAWATAN

Identitas Pasien
Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Data Masalah Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 19
 Survey primer: S: .................................
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Survei sekunder: .................................
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RESUME ASUHAN KEPERAWATANIdentitas Pasien

Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Data Masalah Tujuan Intervensi Evaluasi (SOAP)
Tgl/Jam Tindakan/Kegiatan Paraf

Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 20
 Survey primer: S: .................................
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RESUME ASUHAN KEPERAWATAN

Identitas Pasien
Nama Pasien : .................... (inisial) Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Umur : ...................... Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 21
 Data
Survey primer:
A: .................................
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B: .................................
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D: .................................
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Survei sekunder:
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Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 22
 Data
Survey primer:
A: .................................
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B: .................................
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Survei sekunder:
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Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 23
 Data
Survey primer:
A: .................................
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B: .................................
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Survei sekunder:
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Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 24
 Data
Survey primer:
A: .................................
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B: .................................
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Survei sekunder:
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Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 25
 Data
Survey primer:
A: .................................
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B: .................................
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Survei sekunder:
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Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 26
 Data
Survey primer:
A: .................................
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B: .................................
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Survei sekunder:
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Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
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O: .................................
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A: .................................
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.................................
P: .................................
.................................
.................................
.................................
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.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 27
 Data
Survey primer:
A: .................................
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B: .................................
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C: .................................
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D: .................................
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Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
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O: .................................
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A: .................................
.................................
.................................
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P: .................................
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.................................
.................................
.................................
.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 28
 Data
Survey primer:
A: .................................
.................................
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B: .................................
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C: .................................
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D: .................................
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Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
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O: .................................
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A: .................................
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P: .................................
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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 29
 Data
Survey primer:
A: .................................
.................................
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B: .................................
.................................
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C: .................................
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D: .................................
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Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
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O: .................................
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A: .................................
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P: .................................
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RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 30
 Data
Survey primer:
A: .................................
.................................
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B: .................................
.................................
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C: .................................
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D: .................................
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Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
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O: .................................
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.................................
A: .................................
.................................
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P: .................................
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.................................
.................................
.................................
.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 31
 Data
Survey primer:
A: .................................
.................................
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B: .................................
.................................
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C: .................................
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D: .................................
.................................
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Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
.................................
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O: .................................
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.................................
A: .................................
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P: .................................
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.................................
.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 32
 Data
Survey primer:
A: .................................
.................................
.................................
B: .................................
.................................
.................................
C: .................................
.................................
.................................
D: .................................
.................................
.................................
Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
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O: .................................
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A: .................................
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P: .................................
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.................................
.................................
.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 33
 Data
Survey primer:
A: .................................
.................................
.................................
B: .................................
.................................
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C: .................................
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D: .................................
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.................................
Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
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O: .................................
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A: .................................
.................................
.................................
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P: .................................
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.................................
.................................
.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 34
 Data
Survey primer:
A: .................................
.................................
.................................
B: .................................
.................................
.................................
C: .................................
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D: .................................
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.................................
Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
.................................
.................................
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O: .................................
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.................................
.................................
A: .................................
.................................
.................................
.................................
P: .................................
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.................................
.................................
.................................
.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 35
 Data
Survey primer:
A: .................................
.................................
.................................
B: .................................
.................................
.................................
C: .................................
.................................
.................................
D: .................................
.................................
.................................
Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Identitas Pasien
Nama Pasien : .................... (inisial)
Umur : ......................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
.................................
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.................................
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O: .................................
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.................................
.................................
A: .................................
.................................
.................................
.................................
P: .................................
.................................
.................................
.................................
.................................
.................................
RESUME ASUHAN KEPERAWATAN
Jenis kelami : :Laki-laki Perempuan Tanggal masuk IGD : ..............................
Pukul : ............................
Pelaksanaan
Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 36
 Data
Survey primer:
A: .................................
.................................
.................................
B: .................................
.................................
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C: .................................
.................................
.................................
D: .................................
.................................
.................................
Survei sekunder:
........................................
........................................
........................................
........................................
........................................
........................................
........................................
.......................................
Masalah Tujuan Intervensi Tgl/Jam Tindakan/Kegiatan Paraf Evaluasi (SOAP)
S: .................................
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O: .................................
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.................................
.................................
A: .................................
.................................
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P: .................................
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Logbook_Mahasiswa KGD_Poltekkes_Tanjungkarang | 37
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 38
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 39
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 40
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 41
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 42
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 43
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 44
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 45
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 46
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 47
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 48
 ANALISIS TINDAKAN

Nama Mahasiswa : ...................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus : .........................................................................................................
Jenis tindakan : .........................................................................................................

Kegiatan Yang Dilakukan Yang Diharapkan Pembahasan

Persiapan
alat

Prosedur
tindakan

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 49
 PENCAPAIAN KOMPETENSI

Nama Mahasiswa : ......................................................................................

Semester : ......................................................................................
Tempat Praktek : .....................................................................................

No. Kompetensi Target Paraf Pembimbing (CI)

1 Mengkaji kesadaran (AVPU) 5
2 Pengkajiian primer
Airway (A)
Cross finger 5
Memeriksa jalan nafas 5
Mendengar suara snoring/gargling 5
Memeriksa tanda-tanda cidera servikal 5
Breathing
Look (lihat) 5
Listen (dengar) 5
Feel (rasa) 5
Circulation
Memeriksa nadi karotis 5
Memeriksa denyut nadi distal 5
Memeriksa akral (warna, suhu) 5
Memeriksa CRT 5
3. Pengkajian sekunder
Memeriksa kesadaran (GCS) 5
Memeriksa tekanan darah 5
Memeriksa nadi 5
Memeriksa pernafasan 5
Memeriksa suhu 5
Memeriksa jantung / EKG*) 5
Memeriksa luka dan cidera/trauma 5
4. Merumuskan diagnosis keperawatan 5
5. Menyusun intervensi keperawatan 5
6. Melakukan tindakan keperawatan
Memasang colar neck 2
Finger swab 2
Head tilt chin lift / jaw trust 5
Suction 2
Heamlich manuver 1
Nebulizer 2
Pemasangan orofaringeal air way 2
Pemasangan nasofaringeal tube 1
Pemasangan endotrakheal tube 1
Pemberian oksigen nasal kanul 2
Pemberian oksigen kateter nasal 2
Pemberian oksigen simple mask 2
Pemberian oksigen non rebreathing mask 2
Pemberian oksigen rebreathing mask 1
Kompresi jantung luar 2
Bantuan ventilasi (baging) 2
Menghentikan perdarahan 2
Menjahit luka (hecting) 2
Merawat luka 2
Melakukan pembidaian 1
Injeksi ATS atau obat-obatan lainnya 2
Memberikan obat nitrit sublingual 1
Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 50
Lanjutan..
Memasang IV line 2
Resusitasi cairan 1
Memasang kateter 2
Memasang NGT 2
Kumbah lambung 1
Mengambil sampel darah vena 2
Mengambil sampel darah arteri 1
Memeriksa gula darah sewaktu (rapid) 1
Memakai alat pelindung diri (APD) 5
7. Monitoring & Evaluasi 5
Monitoring EKG 2
Monitoring saturasi oksigen 2
Monitoring tanda-tanda vital 5
Monitoring kesadaran 5
Monitorng air way 5
Monitoring pernafasan 5
Monitoring sirkulasi 5

Mengetahui
Preseptor Akademik, Preseptor Klinik,

............................................. .........................................
N I P ................................................ N I P ......................................

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 51
 FORMAT MAKALAH SEMINAR KASUS

BAB I PENDAHULUAN
A. Latar Belakang
B. Tujuan

BAB II TINJAUAN TEORITIS (sesuai dengan format pendahuluan)

BAB III LAPORAN KASUS (sesuai format laporan askep)

BAB IV PENUTUP
A. Kesimpulan
B. Saran

Log_book_Mahasiswa_KGD_Poltekkes-Tanjungkarang | 52