Logbook Igd 1, Igd 2 Dan Icu

PRAKTIK KLINIK
KEPERAWATAN GAWAT
DARURAT & BENCANA
LOGBOOK
(LEMBAR KERJA MAHASISWA)
POLITEKNIK KESEHATAN
K E S TANJUNGKARANG
ANG A III KEPERAWATAN
PROGRAM STUDI DIPLOMA
III ANG
VISI
PRODI DIPLOMA III KEPERAWATAN TANJUNG KARANG
POLITEKNIK KESEHATAN TANJUNG KARANG
“Menjadi program studi diploma III keperawatan yang profesional, unggul dan
mandiri dalam menghasilkan lulusan perawat vokasional yang terampil dalam
keperawatan gawat darurat pada tahun 2025”
MISI
PRODI DIPLOMA III KEPERAWATAN TANJUNG KARANG
1. Menyelenggarakan pendidikan dan pengajaran dengan unggulan

keperawatan gawat darurat.
2. Menyelenggarakan penelitian yang berkualitas dan inovatif.
3. Menyelenggarakan pengabdian kepada masyarakat yang berbasis penelitian.
LogbookPraktikKlinikKGD &Bencana ii
IDENTITAS MAHASISWA
Foto
NAMA MAHASISWA :...............................................................................
N IM :...................................
PRODI : DIPLOMA III KEPERAWATAN
PERGURUAN TINGGI : POLITEKNIK KESEHATAN TANJUNGKARANG
SEMESTER : GANJIL (V)
KATA PENGANTAR
Praktik klinik keperawatan pada mata kuliah praktik klinik keperawatan gawat dan bencana
merupakan kelanjutan penerapan dari mata kuliah keperawatan gawat darurat dan bencana yang
diperoleh pada pembelajaran teori sebelumnya. Mata kuliah ini berfokus pada kemampuan mahasiswa
untuk dapat melakukan asuhan keperawatan secara professional pada klien yang mengalami masalah
kegawatdaruratan pada semua sistem tubuh dan pada berbagai tingkatan usia yang lazim terjadi. Mata
kuliah ini dilaksanakan setelah mahasiswa menyelesaikan mata kuliah teorinya.
Pelaksanaan praktik klinik keperawatan membutuhkan suatu buku kegiatan mahasiswa (logbook)
yang dapat membantu mahasiswa serta pembimbing dalam melaksanakan proses pembelajaran klinik
secara terarah dan terstandar. Logbook yang disusun akan menjadi panduan dan penuntun bagi
mahasiswa untuk mencapai hasil akhir berupa pencapaian kompetensi-kompetensi yang diharapkan bagi
seorang lulusan Prodi D-III Keperawatan Tanjungkarang, terutama untuk mata kuliah keperawatan
gawatdarurat dan bencana. Untuk membantu mencapai hal tersebut, maka disusunlah logbook praktik
klinik keperawatan keperawatan gawat darurat dan bencana ini.
Logbook ini diharapkan mampu membantu dan memudahkan mahasiswa untuk mencapai tujuan
mata kuliah keperawatan gawatdarurat dan bencana serta kompetensi-kompetensi yang diharapkannya.
Terimakasih kami ucapkan kepada semua pihak yang telah membantu tersusunnya buku kegiatan
mahasiswa (logbook) ini, semoga bermanfaat bagi kita semua.
PROGRAM STUDI DIPLOMA III KEPERAWATAN TANJUNGKARANG
JURUSAN KEPERAWATAN
POLITEKNIK KESEHATAN TANJUNGKARANG
Kampus: Jalan Soekarno-Hatta Nomor 1
BandarLampung Telp/Fax: (0721)703580
LAPORAN PENDAHULUAN GAWAT DAURAT (IGD 1)
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus :.........................................................................................................
A. Gambaran Kasus
1. Definisi
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2. Gambaran Klinis (pengkajian)

a. Tanda & Gejala Umum
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b. Tanda & Gejala Kegawatdaruratan (ABCD)
1) Airway (A)
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2) Breathing (B)
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3) Circulation (C)
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4) Disablity (D)
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c. Tes Diagnostik (pemeriksaan penunjang)
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3. Patofisiologi
B. Diagnosis Keperawatan/Masalah Keperawatan Kegawatdaruratan

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C.Perencanaan Keperawatan/ Algoritme / Protokol Penatalaksanaan

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Daftar Rujukan/ Referensi:
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JURUSAN KEPERAWATAN POLITEKNIK
KESEHATAN TANJUNGKARANG Kampus: Jalan
Soekarno-Hatta Nomor 1 BandarLampung
Telp/Fax: (0721)703580
LAPORAN ASUHAN KEPERAWATAN GAWAT DARURAT (IGD)
Nama Mahasiswa :.................................................... Tempat Praktek :............................................

Semester :....................................................
A. Identitas Pasien
Nama :....................(inisial) Tanggal masuk IGD :........................................
Umur :.................... Pukul :.......................WIB
Jenis kelamin : Laki-laki Perempuan
B. Tindakan Pra Hospital (rumah sakit)

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C. Riwayat Masuk IGD

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D. Pengkajian Primer – Masalah Keperawatan – Intervensi (tindakan) - Evaluasi

Kesadaran (AVPU) : Alert (sadar penuh)  Verbal Pain (nyeri) Unresposive (tidak sadar)
Nadi karotis : teraba tidak teraba
Masalah/diagnosis keperawatan:............................................................................
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Tindakan:.............................................................................................................
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Evaluasi: ............................................................................................................
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Logbook MAhAsiswA_KGD_Poltekkes_TAnjungkARANG | 7
Airway (A) :  kemungkinan trauma cervikal  Tidak ada trauam cervikal
Auskultasi terdengar :  snoring  gargling
Inspeksi tampak sumbatan :  cairan  lidah  edema  benda asing  massa
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Masalah/diagnosis keperawatan: ..........................................................................................................

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Tindakan: ...............................................................................................................................................
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Evaluasi: ................................................................................................................................................
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Breathing (B)
Lihat :  ada grakan dinding dada  tidak ada gerakan dinding dada
Dengar :  terdengar suara nafas  tidak terdengar suara nafas
Rasa :  terasa hembusan nafas  tidak terasa hembusan nafas
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Masalah/diagnosis
keperawatan: ............................................................................................................................
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Tindakan: ...............................................................................................................................................
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Circulation (C)
Nadi :  teraba  tdk teraba
Bila teraba :  cepat  lambat
 kuat  lemah
 normal
Akral teraba :  dingin  hangat
Warna akral :  pucat  sianosis
Kelembabab :  lembab  Kering
Perdarahan : ± ................ ml, lokasi perdarahan ......................................................................
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Masalah/diagnosis
keperawatan: ............................................................................................................................
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Tindakan: ...............................................................................................................................................
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Disability (D)
GCS : E ......... V ............ M ............, = .......................
Fraktur : ...........................................................................................................................
Dislokas : ..........................................................................................................................
Lateralisasi :  Pupil Isokor  pupil anisokor
Paralisis/parese :  kanan  kiri
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Masalah/diagnosis
keperawatan: ............................................................................................................................
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Tindakan: ...............................................................................................................................................
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Evaluasi: ................................................................................................................................................
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Analisis Data Primer
Data Pathway/ Patofisiologi Masalah

Pengkajian primer
A:.....................................................
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C: .....................................................
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D: .....................................................
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E. Pengkajian Sekunder
Keluhan utama:
Riwayat Kesehatan Sekarang:
Riwayat Kesehatan Lalu:
Keadaan Umum dan Tanda-tanda Vital :

Kesadaran........................................GCS:........................,TD:...............mmHg, Nadi:..............kali/menit,
RR:...........kali/menit, suhu:.........oC, Nyeri: ....................................................., SaO2:................
Pengkajian Head to Toe

Kepala
Leher
Thorak
Abdomen
Ekstremitas
Integumen
Pemeriksaan Penunjang & Terapi Medis
Radiologi LaboratoriumDarah TerapiMedis
Analisis Data Sekunder
Data Pathway/Patofisiologi Masalah

Pengkajian sekunder
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F. Diagnosis Keperawatan
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G. Perencanaan Keperawatan
Tujuan Intervensi Keperawatan

H. Pelaksanaan dan Evaluasi Keperawatan
Tanggal & Jam Implementasi Paraf & Nama Evaluasi (SOAP)

PROGRAM STUDIDIPLOMAIIIKEPERAWATAN TANJUNGKARANG
JURUSAN KEPERAWATAN
POLITEKNIKKESEHATANTANJUNGKARANG
Kampus: Jalan Soekarno-HattaNomor
1BandarLampung Telp/Fax: (0721)703580
FORMAT PENILAIAN
LAPORAN PENDAHULUAN DAN LAPORAN ASKEP
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
TempatPraktek : .....................................................................................................................
A. Laporan Pendahuluan
Nilai (N)
No. Aspek Penilaian Bobot (B) NxB Keterangan
(1-10)
1. Kelengkapan isi laporan sesuai format 2
2. Kualitas isi laporan 4
3. Sistematika dan kaidah penulisan 1
4. Responsi 2
5. Ketepatan mengumpulkan laporan 1
Total Nilai
B. Laporan Asuhan Keperawatan
Nilai (N)
No. Aspek Penilaian Bobot( B) N xB Keterangan
(1-10)
1. Kelengkapan isi laporan (N1) (20%) 10 Total Nilai=
2 Kualitas isi laporan (N2) (50%) (N1x20%) +
a. Kelengkapan & keabsahan pengkajian 3 (N2x50%) +
b. Perumusan diagnosis keperawatan 1 (N3x30%)
c. Penyusunan rencana keperawatan 3
d. Penulisan implemetasi dan evaluasi 3
3. Bimbingan laporan askep (N3) (30%)
a. Kedisiplinan & ketekunan 5
b. Sikap selama bimbingan laporan 5
Total Nilai
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Pembimbing Lahan,
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JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
C. Laporan Pendahuluan
Nilai (N)
(1-10)
4. Responsi 2
Total Nilai
D. Laporan Asuhan Keperawatan
Nilai (N)
(1-10)
e. Kelengkapan & keabsahan pengkajian 3 (N2x50%) +
f. Perumusan diagnosis keperawatan 1 (N3x30%)
g. Penyusunan rencana keperawatan 3
h. Penulisan implemetasi dan evaluasi 3
c. Kedisiplinan & ketekunan 5
d. Sikap selama bimbingan laporan 5
Total Nilai
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Pembimbing Akademik,
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JURUSAN KEPERAWATAN
FORMAT PENILAIAN
ANALISIS TINDAKAN DAN RESUME ASKEP
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
A. Analisis Tindakan
Nilai (N)
(1-10)
Total Nilai
B. Resume Askep
Nilai (N)
No. Aspek Penilaian Bobot(B) NxB Keterangan
(1-10)
Total Nilai
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Pembimbing Lahan,
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JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
Nilai (N)
(1-10)
Total Nilai
B. Resume Askep
Nilai (N)
(1-10)
Total Nilai
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JURUSAN KEPERAWATAN
POLITEKNIK KESEHATAN TANJUNGKARANG
LAPORAN PENDAHULUAN GAWAT DAURAT (IGD 2)
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus :.........................................................................................................
A. Gambaran Kasus
1. Definisi
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1) Airway (A)
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2) Breathing (B)
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3) Circulation (C)
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4) Disablity (D)
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c. Tes Diagnostik (pemeriksaan penunjang)
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3. Patofisiologi
B. Diagnosis Keperawatan/Masalah Keperawatan Kegawatdaruratan

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C.Perencanaan Keperawatan/ Algoritme / Protokol Penatalaksanaan

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Daftar Rujukan/ Referensi:
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
............................................................................................................................................................................
JURUSAN KEPERAWATAN POLITEKNIK
KESEHATAN TANJUNGKARANG Kampus: Jalan
Soekarno-Hatta Nomor 1 BandarLampung
Telp/Fax: (0721)703580
LAPORAN ASUHAN KEPERAWATAN GAWAT DARURAT (IGD 2)
Nama Mahasiswa :.................................................... Tempat Praktek :............................................

Semester :....................................................
A. Identitas Pasien
Umur :.................... Pukul :.......................WIB
B. Tindakan Pra Hospital (rumah sakit)

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
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.............................................................................................................................................................
C. Riwayat Masuk IGD

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
D. Pengkajian Primer – Masalah Keperawatan – Intervensi (tindakan) - Evaluasi

Kesadaran (AVPU) : Alert (sadar penuh)  Verbal Pain (nyeri) Unresposive (tidak sadar)
Nadi karotis : teraba tidak teraba
Masalah/diagnosis keperawatan:............................................................................
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Tindakan:.............................................................................................................
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Evaluasi: ............................................................................................................
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Airway (A) :  kemungkinan trauma cervikal  Tidak ada trauam cervikal
Auskultasi terdengar :  snoring  gargling
Inspeksi tampak sumbatan :  cairan  lidah  edema  benda asing  massa
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Masalah/diagnosis keperawatan: ..........................................................................................................

................................................................................................................................................................
Tindakan: ...............................................................................................................................................
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Evaluasi: ................................................................................................................................................
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Breathing (B)
Lihat :  ada grakan dinding dada  tidak ada gerakan dinding dada
Dengar :  terdengar suara nafas  tidak terdengar suara nafas
Rasa :  terasa hembusan nafas  tidak terasa hembusan nafas
..................................................................................................................................................
..................................................................................................................................................
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..................................................................................................................................................
Masalah/diagnosis
keperawatan: ............................................................................................................................
......................
..................................................................................................................................................
Tindakan: ...............................................................................................................................................
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Evaluasi: ................................................................................................................................................
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Circulation (C)
Nadi :  teraba  tdk teraba
Bila teraba :  cepat  lambat
 kuat  lemah
 normal
Akral teraba :  dingin  hangat
Warna akral :  pucat  sianosis
Kelembabab :  lembab  Kering
Perdarahan : ± ................ ml, lokasi perdarahan ......................................................................
..................................................................................................................................................
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..................................................................................................................................................
Masalah/diagnosis
keperawatan: ............................................................................................................................
......................
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Tindakan: ...............................................................................................................................................
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Evaluasi: ................................................................................................................................................
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Disability (D)
GCS : E ......... V ............ M ............, = .......................
Fraktur : ...........................................................................................................................
Dislokas : ..........................................................................................................................
Lateralisasi :  Pupil Isokor  pupil anisokor
Paralisis/parese :  kanan  kiri
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..................................................................................................................................................
Masalah/diagnosis
keperawatan: ............................................................................................................................
......................
..................................................................................................................................................
Tindakan: ...............................................................................................................................................
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Evaluasi: ................................................................................................................................................
............................................................................................................................ ...................................
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............................................................................................................................ ...................................
............................................................................................................................ ...................................
Analisis Data Primer
Data Pathway/ Patofisiologi Masalah

Pengkajian primer
A:.....................................................
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B:.....................................................
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C: .....................................................
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D: .....................................................
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E. Pengkajian Sekunder
Keluhan utama:
Riwayat Kesehatan Sekarang:
Riwayat Kesehatan Lalu:

Kesadaran........................................GCS:........................,TD:...............mmHg, Nadi:..............kali/menit,
RR:...........kali/menit, suhu:.........oC, Nyeri: ....................................................., SaO2:................
Pengkajian Head to Toe

Kepala
Leher
Thorak
Abdomen
Ekstremitas
Integumen
Pemeriksaan Penunjang & Terapi Medis
Radiologi LaboratoriumDarah TerapiMedis
Analisis Data Sekunder

Pengkajian sekunder
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F. Diagnosis Keperawatan
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G. Perencanaan Keperawatan

H. Pelaksanaan dan Evaluasi Keperawatan

JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
TempatPraktek : .....................................................................................................................
Nilai (N)
(1-10)
4. Responsi 2
Total Nilai
Nilai (N)
(1-10)
Total Nilai
...............................,...............................................
Pembimbing Lahan,
.......................................................
JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
C. Laporan Pendahuluan
Nilai (N)
(1-10)
4. Responsi 2
Total Nilai
D. Laporan Asuhan Keperawatan
Nilai (N)
(1-10)
e. Kelengkapan & keabsahan pengkajian 3 (N2x50%) +
f. Perumusan diagnosis keperawatan 1 (N3x30%)
g. Penyusunan rencana keperawatan 3
h. Penulisan implemetasi dan evaluasi 3
c. Kedisiplinan & ketekunan 5
d. Sikap selama bimbingan laporan 5
Total Nilai
...............................,...............................................
.......................................................
JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
Nilai (N)
(1-10)
Total Nilai
B. Resume Askep
Nilai (N)
(1-10)
Total Nilai
...............................,...............................................
Pembimbing Lahan,
.......................................................
JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
Nilai (N)
(1-10)
Total Nilai
B. Resume Askep
Nilai (N)
(1-10)
Total Nilai
...............................,...............................................
......................................................
JURUSAN KEPERAWATAN
LAPORAN PENDAHULUAN KASUS KRITIS (ICU)
Nama Mahasiswa : .........................................................................................................

Semester : . ........................................................................................................
Tempat Praktek : .........................................................................................................
Kasus :.........................................................................................................
A. Gambaran Kasus
1. Definisi
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1) Airway (A)
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2) Breathing (B)
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JURUSAN KEPERAWATAN
3) Circulation (C)
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4) Disablity (D)
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. c. Tes Diagnostik (pemeriksaan penunjang)
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3. Patofisiologi /Pathway (Gambar /Bagan)
B. Diagnosis Keperawatan /MasalahKeperawatan

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C. Perencanaan Keperawatan
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Daftar Rujukan/Referensi:
.............................................................................................................................................................................
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.............................................................................................................................................................................
PROGRAM STUDI DIPLOMA III KEPERAWATAN TANJUNG KARANG
JURUSAN KEPERAWATAN
LAPORAN ASUHAN KEPERAWATAN KRITIS (ICU)
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek :.........................................................................................................
A. Identitas Pasien
Umur :.................... Pukul :.......................WIB
B. Keluhan utama
.............................................................................................................................................................
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C. Riwayat penyakit sekarang

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D. Riwayat Penyakit Dahulu

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E. Pengkajian Primer
Airway (A) :
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Breathing (B) :
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.
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Circulation(C):...................................................................................................................................................
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Disability (D) :
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F. Pengkajian Sekunder

Kesadaran :........................................GCS :........................, TD:..................mmHg,
Nadi:...........kali/menit, RR :...........kali/menit, Suhu :.........oC, 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

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

Diagnosis Keperawatan Tujuan Intervensi Keperawatan
J. Pelaksanaan dan Evaluasi Keperawatan

JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
TempatPraktek : .....................................................................................................................
Nilai (N)
(1-10)
4. Responsi 2
Total Nilai
Nilai (N)
(1-10)
Total Nilai
...............................,...............................................
Pembimbing Lahan,
.......................................................
JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
TempatPraktek : .....................................................................................................................
Nilai (N)
(1-10)
4. Responsi 2
Total Nilai
Nilai (N)
(1-10)
Total Nilai
...............................,...............................................
Pembimbing Akademik
.......................................................
JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
Nilai (N)
(1-10)
Total Nilai
B. Resume Askep
Nilai (N)
(1-10)
Total Nilai
...............................,...............................................
Pembimbing Lahan,
.......................................................
JURUSAN KEPERAWATAN
FORMAT PENILAIAN
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
Nilai (N)
(1-10)
Total Nilai
B. Resume Askep
Nilai (N)
(1-10)
Total Nilai
...............................,...............................................
.......................................................
JURUSAN KEPERAWATAN
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 / jawtrust 5
Suction 2
Heamlich manuver 1
Nebulizer 2
Pemasangan orofaringeal airway 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 nonrebreathing 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
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 airway 5
Monitoring pernafasan 5
Monitoring sirkulasi 5
Mengetahui
Pembimbing akademik, Pembimbing Wahana (CI RS),
................................................ ................................................
JURUSAN KEPERAWATAN
BandarLampung
Telp/Fax: (0721)703580
FORMAT PENILAIAN
KOMPETENSI TINDAKAN DAN PENAMPILAN KLINIK
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
A. Kompetensi Tindakan
Nilai (N)
No. AspekPenilaian Bobot(B) NxB Keterangan
(1-10)
2. Persentase pencapaian kompetensi 5
Total Nilai
B. Penampilan Klinik
Nilai (N)
(1-10)
1. Pengetahuan (knowledge) (N1) (20%) Total Nilai=
Kemampuan menjelaskan 4 (N1x20%) +
Kemampuan berpendapat 3 (N2x40%) +
Respon dan kemampuan menjawab 3 (N3x40%)
2. Sikap (afektif) (N2) (40%)
Kedisiplinan 2
Ketekunan 2
Tanggung jawab 2
Kerjasama 2
Ahlak/sopan santun 2
3. Keterampilan (psikomotor)(N3) (40%)
Melakukan pengkajian 2
Merumuskan diagnosis keperawatan 1
Menyusun rencana keperawatan 2
Melakukan tindakan keperawatan 2
Melakukan monitoring & evaluasi 1
Interpersonal (komunikasi,sosialisasi, dsb) 2
Total Nilai
...............................,...............................................
Pembimbing Lahan,
.......................................................
JURUSAN KEPERAWATAN
BandarLampung
Telp/Fax: (0721)703580
FORMAT PENILAIAN
KOMPETENSI TINDAKAN DAN PENAMPILAN KLINIK
Nama Mahasiswa : .........................................................................................................

Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
A. Kompetensi Tindakan
Nilai (N)
No. AspekPenilaian Bobot(B) NxB Keterangan
(1-10)
2. Persentase pencapaian kompetensi 5
Total Nilai
B. Penampilan Klinik
Nilai (N)
(1-10)
1. Pengetahuan (knowledge) (N1) (20%) Total Nilai=
Kemampuan menjelaskan 4 (N1x20%) +
Kemampuan berpendapat 3 (N2x40%) +
Respon dan kemampuan menjawab 3 (N3x40%)
2. Sikap (afektif) (N2) (40%)
Kedisiplinan 2
Ketekunan 2
Tanggung jawab 2
Kerjasama 2
Ahlak/sopan santun 2
3. Keterampilan (psikomotor)(N3) (40%)
Melakukan pengkajian 2
Merumuskan diagnosis keperawatan 1
Menyusun rencana keperawatan 2
Melakukan tindakan keperawatan 2
Melakukan monitoring & evaluasi 1
Interpersonal (komunikasi,sosialisasi, dsb) 2
Total Nilai
...............................,...............................................
.......................................................
JURUSAN KEPERAWATAN
FORMAT PENILAIAN
SEMINAR
Kelompok : .........................................................................................................
Semester : .........................................................................................................
Tempat Praktek : .....................................................................................................................
Nilai (N)
(1-10)
1. Persiapan (N1) (40%) Total Nilai=
Kesiapan dan kualitas makalah 4 (N1x40%) +
Distribusi makalah 2 (N2x60%)
Kesiapan alat, tempat dan perangkat 4
3. Pelaksanaan (N2) (60%)
Kemampuan mempresentasikan 1
Distribusi dan kemampuan menjawab 3
Sikap dalam diskusi 3
Kecepatan/respon dalam menjawab 3
Total Nilai
...............................,...............................................
Daftar Nama Mahasiswa:
1. ...................................................... Pembimbing,
2. ......................................................
3. ......................................................
4. ......................................................
5. ...................................................... ......................................................
6. ......................................................
7. .......................................................
8. .......................................................
9. .......................................................

Logbook Igd 1, Igd 2 Dan Icu

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Logbook Igd 1, Igd 2 Dan Icu

Diunggah oleh

Hak Cipta:

Format Tersedia

PRAKTIK KLINIK

1. Menyelenggarakan pendidikan dan pengajaran dengan unggulan

NAMA MAHASISWA :...............................................................................

PRODI : DIPLOMA III KEPERAWATAN

PERGURUAN TINGGI : POLITEKNIK KESEHATAN TANJUNGKARANG

SEMESTER : GANJIL (V)

LAPORAN PENDAHULUAN GAWAT DAURAT (IGD 1)

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

2. Gambaran Klinis (pengkajian)

B. Diagnosis Keperawatan/Masalah Keperawatan Kegawatdaruratan

C.Perencanaan Keperawatan/ Algoritme / Protokol Penatalaksanaan

LAPORAN ASUHAN KEPERAWATAN GAWAT DARURAT (IGD)

Nama Mahasiswa :.................................................... Tempat Praktek :............................................

B. Tindakan Pra Hospital (rumah sakit)

C. Riwayat Masuk IGD

D. Pengkajian Primer – Masalah Keperawatan – Intervensi (tindakan) - Evaluasi

Masalah/diagnosis keperawatan: ..........................................................................................................

Data Pathway/ Patofisiologi Masalah

Riwayat Kesehatan Lalu:

Keadaan Umum dan Tanda-tanda Vital :

Pengkajian Head to Toe

Data Pathway/Patofisiologi Masalah

Tujuan Intervensi Keperawatan

Tanggal & Jam Implementasi Paraf & Nama Evaluasi (SOAP)

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

B. Laporan Asuhan Keperawatan

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

D. Laporan Asuhan Keperawatan

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

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

LAPORAN PENDAHULUAN GAWAT DAURAT (IGD 2)

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

2. Gambaran Klinis (pengkajian)

B. Diagnosis Keperawatan/Masalah Keperawatan Kegawatdaruratan

C.Perencanaan Keperawatan/ Algoritme / Protokol Penatalaksanaan

LAPORAN ASUHAN KEPERAWATAN GAWAT DARURAT (IGD 2)

Nama Mahasiswa :.................................................... Tempat Praktek :............................................

B. Tindakan Pra Hospital (rumah sakit)

C. Riwayat Masuk IGD

D. Pengkajian Primer – Masalah Keperawatan – Intervensi (tindakan) - Evaluasi

Masalah/diagnosis keperawatan: ..........................................................................................................

Data Pathway/ Patofisiologi Masalah

Riwayat Kesehatan Lalu:

Keadaan Umum dan Tanda-tanda Vital :

Pengkajian Head to Toe

Data Pathway/Patofisiologi Masalah

Tujuan Intervensi Keperawatan

Tanggal & Jam Implementasi Paraf & Nama Evaluasi (SOAP)

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

B. Laporan Asuhan Keperawatan

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

D. Laporan Asuhan Keperawatan

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

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

LAPORAN PENDAHULUAN KASUS KRITIS (ICU)

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

2. Gambaran Klinis (pengkajian)

B. Diagnosis Keperawatan /MasalahKeperawatan

LAPORAN ASUHAN KEPERAWATAN KRITIS (ICU)

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

C. Riwayat penyakit sekarang

D. Riwayat Penyakit Dahulu