FORMAT LAPORAN KASUS KEPERAWATAN GAWAT DARURAT PROGRAM

STUDI ILMU KEPERAWATAN STIKES AL-INSYIRAH

A. INFORMASI UMUM

Nama : …………………………………................................
Umur :……………………………….....................................
Tanggal lahir :………………….........................................................
Jenis kelamin :……………….............................................................
Suku bangsa :.....................................................................................

Tanggal masuk :.....................................................................................

Tanggal Pengkajian :.....................................................................................
Dari/Rujukan :.....................................................................................
Diagnosa Medik :.....................................................................................
Nomor Medical Record :.....................................................................................

B. KELUHAN UTAMA
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PENGKAJIAN PRIMER
Airway :...............................................................................................................
Breathing :................................................................................................................
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Circulation :................................................................................................................
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Disability :................................................................................................................
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Exposure :................................................................................................................
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Foley kateter :................................................................................................................
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Gastric Tube :………………………………………………………………………….
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Heart Monitor :………………………………………………………………………….
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PENGKAJIAN SEKUNDER
C. Riwayat Kesehatan Sebelumnya
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D. Riwayat Kesehatan Keluarga

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E. Pemeriksaan Fisik

 Tanda-tanda vital : TD :…….. Suhu :……

Nadi:…….. Pernafasan :……

 Tinggi Badan :…..... Berat Badan :..…..

I. Kepala
Rambut : panjang/pendek/tanpa rambut/kotor/mudah rontok/gatal-gatal
Lain-lain :………………………….………………………………………….........…..
Mata : ikterik/midriasis/pakai kacamata/contact lens/gangguan penglihatan
Lain-lain :………………………….………………………………………….........…..
Hidung: perdarahan/sinusitis/gangguan penciuman/malformasi/terpasang NGT
Lain-lain :………………………….………………………………………….........…..
Mulut : kotor/bau/terpasang ETT/Gudel/perdarahan/lidah kotor/gangguan pengecapan
Lain-lain :………………………………………………………………………............
Gigi : gigi palsu/kotor/kawat gigi/karies/tidak ada gigi
Lain-lain :………………………………………………………………………............
Telinga : perdarahan/terpasang ailat bantu dengar/infeksi/gangguan pendengaran
Lain-lain :………………………………………………………………………………

II. Leher : pembesaran KGB/kaku kuduk/terpasang trakeostoml/ JVP:

Lain-lain :………………………………………………………………………………

III. Dada
Inspeksi :......................................................................................................................
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Palpasi :......................................................................................................................
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Perkusi :......................................................................................................................
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 Auskultasi :……………………………………………………………………………….
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IV. Tangan :utuh/Iuka/lecet/sianosis/capillaryferill/clubbing finger/dingin/fraktur/edema

Lain-lain :......................................................................................................................

V. Abdomen :
Inspeksi : ....................................................................................................................
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Palpasi : ....................................................................................................................
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Perkusi : ....................................................................................................................
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Auskultasi : ....................................................................................................................
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IV. Genitalia : perdarahan/terpasang kateter/trauma/malformasi/menstruasi/infeksi

Lain-lain : .....................................................................................................................

VII. Kaki : Fraktur/edema/malformasi/luka/infeksi/keganasan/sianis/dingin

Lain-lain :......................................................................................................................
VIII. Punggung: Lordosis/kiposis/skoliosis/luka/dekubitus/infeksi
Lain-lain:......................................................................................................................

Hasil Pemeriksaan Laboratorium dan Diagnostik

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Medikasi /obat-obatan yang diberikan saat ini

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ANALISA DATA
MASALAH
No SUMBER DATA ETIOLOGI
KEPERAWATAN
Diagnosa Keperawatan
1. ..........................................................................................................................................
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2. ..........................................................................................................................................
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3. ..........................................................................................................................................
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4. ..........................................................................................................................................
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Pekanbaru, ………………….
Mahasiswa

(…………………………)
 FORMAT
RENCANA ASUHAN KEPERAWATAN

Nama Pasien : Nama Mahasiswa :

Ruang : NIM :
No. M.R :

No Diagnosa keperawatan NOC NIC

FORMAT IMPLEMENTASI DAN EVALUASI

No
Nama &
. Hari/Tgl Implementasi Jam Evaluasi
TTD
DX
Pekanbaru, ………………….
Mahasiswa

(……………………..)