PROGRAM STUDI DIPLOMA III KEPERAWATAN TANJUNGKARANG

JURUSAN KEPERAWATAN
POLITEKNIK KESEHATAN TANJUNGKARANG
Kampus: Jalan Soekarno-Hatta tfomor 1 Bandar Lampung Telp/Fax: (0721 703580

LAPORAN ASUHAN KEPERAWATAN GAWAT DARURAT (IGD)

Nama Mahasiswa : Abdi Setiadi Tempat Praktek : IGD RS Bhayangkara

Semester : II

A. Identitas Pasien
Nama : An. (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: .............................................................................................................
Airway (A) :  kemungkinan trauma 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: .............................................................................................................
Breathing (B) : Lihat:  ada gerakan 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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Evaluasi: .............................................................................................................
Circulation (C) : Nadi  teraba  tdk teraba,  cepat  lambat,  kuat  lemah,  normal Akral
teraba  dingin  hangat, warna  pucat  sianosis,  lembab,  normal
 perdarahan, ± ............ ml, di .............................................................................
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Masalah/diagnosis keperawatan: ............................................................................
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Tindakan: .............................................................................................................
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Evaluasi: .............................................................................................................
Disability (D) : GCS: E ... V ... M ...,  Fraktur,  Dislokasi, Lateralisasi: Pupil  Isokor  Anisokor (....
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 Paralisis/parese kanan,  Paralisis/parese kiri
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Masalah/diagnosis keperawatan: ............................................................................
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Tindakan: .............................................................................................................
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Evaluasi: .............................................................................................................

Analisis Data Primer

Data Pathway/Patofisiologi Masalah

Pengkajian primer
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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: ......... o C, Nyeri: ....................................................., SaO2: ................

Pengkajian Head to Toe

Kepala

Leher

Thorak

Abdomen

Ekstremitas

Integumen

Pemeriksaan Penunjang & Terapi Medis

Radiologi Laboratorium Darah Terapi Medis

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