Prodi Pendidikan Profesi Ners

Jurusan Keperawatan
Poltekkes Kemenkes Bengkulu

LAPORAN PENDAHULUAN
PRAKTIK PROFESI NERS
ASUHAN KEPERAWATAN GAWAT DARURAT

Pada Kasus Meningitis

Nama : Elwina Dwi Putri

NIM : P051204210

Menyetujui,
Preceptor Akademik

(Dahrizal, S.Kp.,MPH)

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN BENGKULU
JURUSAN KEPERAWATAN PROGRAM STUDI PENDIDIKAN PROFESI NERS
TAHUN AKADEMIK 2021/2022

Prodi Pendidikan Profesi Ners

Jurusan Keperawatan
Poltekkes Kemenkes Bengkulu
 LAPORAN KASUS KELOLAAN
PRAKTIK PROFESI NERS
ASUHAN KEPERAWATAN KRITIS

____________________________________________

Nama : Apriliani Nur Aisiyah

NIM : P05120421008

PRECEPTOR INSTITUSI PENDIDIKAN PRECEPTOR LAHAN PRAKTIK

(Dahrizal, S.Kp.,MPH) (Ns. Yatimah., S.Kep)

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN BENGKULU
JURUSAN KEPERAWATAN PROGRAM STUDI PENDIDIKAN PROFESI NERS
TAHUN AKADEMIK 2020/2021

Prodi Pendidikan Profesi Ners

Jurusan Keperawatan
Poltekkes Kemenkes Bengkulu

LAPORAN INOVASI IMPLEMENTASI KEPERAWATAN

PRAKTIK PROFESI NERS
 ASUHAN KEPERAWATAN GAWAT DARURAT
____________________________________________
____________________________________________

Nama : Apriliani Nur Aisiyah

NIM : P05120421008

PRECEPTOR INSTITUSI PENDIDIKAN PRECEPTOR LAHAN PRAKTIK

(Dahrizal, S.Kp.,MPH) (Ns. Yatimah., S.Kep)

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN BENGKULU
JURUSAN KEPERAWATAN PROGRAM STUDI PENDIDIKAN PROFESI NERS
TAHUN AKADEMIK 2021/2022

Lampiran 11
FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KRITIS
PRODI PENDIDIKAN PROGRAM PROFESI NERS
JURUSAN KEPERAWATAN POLTEKKES KEMENKES BENGKULU

Tanggal Pengkajian : Tanggal Masuk :

Ruang Kelas : Nomor Register :
Diagnose Medis :
A. IDENTITAS KLIEN
Nama Klien :

Jenis Kelamin :
Usia/Tanggal lahir :
Status perkawinan :
Agama :
Suku Bangsa :
Pendidikan :
Bahasa yang digunakan :

Pekerjaan :
Alamat :
Nama Penanggung Jawab :
Alamat Penanggung Jawab :

B. KELUHAN UTAMA MRS

1. Keluhan Utama Masuk Rumah Sakit
Hari/Tanggal/Jam MRS : / /

2. Keluhan Utama dan Kronologi Masuk ruang HCU/ICU/ICCU

Hari/Tanggal/Jam Masuk HCU/ICU/ICCU: / /
 3. Penanganan yang telah dilakukan
(sebelum masuk HCU/ICU/ICCU, saat masuk RS atau saat diruangan lain)

C. PENGKAJIAN PRIMER KEPERAWATAN KRITIS

Hari/Tanggal/Jam Pengkajian : / /
Keadaan Umum :
Keluhan saat dikaji :

(Keluhan, Penggunaan alat, Pemeriksaan fisik, Pemeriksaan penunjang )

(A) ................................................................................................
Airway ................................................................................................
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(B) ................................................................................................
Breathing ................................................................................................
Jika menggunakan ................................................................................................
ventilator jelaskan ................................................................................................
mode yang ................................................................................................
digunakan ................................................................................................
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(C) Circulation ................................................................................................

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(D) Disability Pengkajian Kesadaran

Skor GCS : Eyes ................. Verbal ...............
Motorik .......................
Pupil, Ukuran Kiri ................... Ukuran kanan ....................
Reflek cahaya ............../..................
Motorik / Sensori :
Pengkajian Nyeri :
Verbal :
P : ...........................................................................................
..
Q : ..........................................................................................
......
Lampirkan instrumen R : ..........................................................................................
CPOT, Braden Scale, ......
Morse Scale, RASS S : ...........................................................................................
.....
T : ...........................................................................................
.....
Non Verbal :
Score
CPOT : ...................................................................................
.....
Pengkajian resiko dekubitus
Score Braden
Scale : .............................................................................
Pengkajian resiko jatuh
Score Morse
scale : ...............................................................................
Pengkajian manajemen Sedasi :
Pengkajian
sadasi : ...............................................................................

Score
RASS : ..........................................................................
.....
(E) Elimination Intake (Sebelumnya) Output ( sebelumnya)
Parental : ......................... cc Urine : ............................. cc
Med. Drip : ......................... cc IWL : ............................. cc
Oral/NGT : ......................... cc Drain : ............................. cc
Jumlah : ..........................cc Muntah : ............................ cc
BAB : ............................ cc
Jumlah : .............................. cc

Balance cairan : In ................... – Out ................. = ................... cc

Hitung Kebutuhan cairan aktual :

Status Nutrisi :
Berat Badan : ............ Kg Tinggi Badan : ............ cm IMT:.........kg/cm
Hitung Kebutuhan Nutrisi actual :

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D. PEMERIKSAAN FISIK
(Inspeksi, Auskultasi, Palpasi, Perkusi, Olfaksi)
Kepala & Leher ...................................................................................................
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Dada ...................................................................................................
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Genetalia ...................................................................................................
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Ektremitas ...................................................................................................
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E. PEMERIKSAAN PENUNJANG
1. Laboratorium
Pemeriksaan Nilai Satuan Hasil Tanggal
Normal Pemeriksaan Pemeriksaan
Hematologi
Hemoglobin
Hematoktit
Eritrosit
Leukosit
Trombosit
LED
MCV
MCH
MCHC
Waktu protrombin
PPT control
Waktu tromboplastin
Kimia Klinik
Fungsi Hati
Bilirubin total
Bilirubin indirect
Bilirubin direct
Albumin
Globulin
SGOT/AST
SGPT/ALT
Fungsi Ginjal
Ureum
Creatinin
Asam Urat
Fungsi Jantung
CPK
CK-MB
LDH
Fungsi metabolisme KH
GDS
GD Puasa
GD PP
HBA 1C
Fungsi Pankreas
Lipase
Amilase
L iron
TIBC
Elektrolit
Natrium
Kalium
Chlorida
Kalsium
Phospor
Profila Lipid
Kolestreol total
HDL
LDL
Trigliserida
Analisa Gas Darah
pH
pCO2
pO2
HCO3
AADO2
Laktat
Base Exces

Pemeriksaan Penunjang (Radiologi, CT Scan, Endoskopi, Histopatologi, dll)

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Penatalaksanaan Kolaborasi Terapi Medis :
 ANALISA DATA
NAMA PASIEN …………………… UMUR :…………………….
RUANGAN …………………… NO.REG :………………….

NO DATA SENJANG ETIOLOGI MASALAH

 DAFTAR DIAGNOSA KEPERAWATAN KRITIS BERDASARKAN PRIORITAS

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NAMA PASIEN :……………………………
RUANGAN :……………………………
NO DIAGNOSA KEPERAWATAN
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PERENCANAAN KEPERAWATAN
UMUR : …………………………….
NO.REG : ……………………………
RENCANA TINDAKAN KEPERAWATAN
TUJUAN /KRITERIA HASIL INTERVENSIKEPERAWATAN RASIONAL
(NOC) (NIC)
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NO DIAGNOSA KEPERAWATAN
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RENCANA TINDAKAN KEPERAWATAN
TUJUAN /KRITERIA HASIL INTERVENSI KEPERAWATAN RASIONAL
(NOC) (NIC)
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CATATAN PERKEMBANGAN KEPERAWATAN KRITIS TERINTEGRASI
 NAMA PASIEN :…………………………… UMUR : …………………………….
RUANGAN :…………………………… HARI KE : ……………………………

SOAP AWAL SHIFT ............... S-O-A-P SELESAI SHIFT ..............................

Subjektif & Objektif Subjektif & Objektif
 Airway  Airway

 Breathing  Breathing

 Circulation  Circulation

 Disability  Disability

 Eliminasi  Eliminasi

Analisis Analisis

Planning Planning
 LEMBAR IMPLEMENTASI DAN MONITORING KEPERAWATAN KRITIS
PRODI PENDIDIKAN PROFESI NERS
JURUSA KEPERAWATAN POLTEKKES KEMNEKS BENGKULU
Nama Pasien : Usia :
Diagnosa Medis : Hari/Tanggal :

Pukul
Tekanan Darah
Frek. Nadi
Frek. Nafas
HEMODINAMIK

Suhu
Kesadaran
Irama EKG
CPOT
CVP
SaO2
Mode Ventilator
PEEP/CPAP
RESPIRASI

RR
TV
FiO2
pH
pCO2
AGD

HCO3
SaO2
BE
Ukuran Pupil
Reaksi cahaya
NEURO

Kaki
Tangan
GCS
Parental

Med. Drip
INPUT

Oral/NGT

Urine
OU
BAB

IWL

Drain

Muntah

Aktifitas keperawatan yang dilakukan :

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 Lampiran 12
KEGIATAN AKTIVITAS HARIAN / LOGBOOK

TT
HARI/ TTD
AKTIVIT RESPON D
TGL/ KENDALA RTL PEM
N AS PASIEN MH
JAM B
O. S