Fomat Igd Oke
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ASUHAN KEPERAWATAN
PADA .. DENGAN DIAGNOSA MEDIS .
DI INSTALASI GAWAT DARURAT (IGD)
RSUP Dr. KARIADI SEMARANG
Disusun untuk Memenuhi Tugas pada Praktik Klinik Stase Gawat DaruratPembimbing Klinik : ...
Pembimbing Akademik : ...
Oleh:
.
.
PROGRAM PROFESI NERS ANGKATAN XXVI
JURUSAN KEPERAWATAN FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
SEMARANG
2015
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ASUHAN KEPERAWATAN
Tanggal pengkajian : ............................................. am : ............................Tanggal masuk : ............................................. am : ............................!uang : "GD
A. I !"#$#%. Klien$Pasien
a. %ama &"nisial' : .................................................................... b. %(. !ekam medik : ....................................................................). *mur : ....................................................................d. enis kelamin : .....................................................................e. Agama : .....................................................................+. Pendidikan : .....................................................................g. Pekerjaan : .....................................................................h. Suku : .....................................................................i. ,ahasa : .....................................................................
j. Alamat : .....................................................................k. Diagn(sa Medis : .....................................................................
-. "dentitas Penanggung awaba. %ama &"nisial' : .....
b. *mur : .). enis kelamin : .d. Alamat : ..e. ubungan dengan klien : ..
'. P!" %*$%" Pr$+!r
#. Airwa/ ....
........................
........................................................................................................................
....
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....-. ,reathing
...............
....
....
0. 1ir)ulati(n:
........
........................................................................................................................
2. Disabilit/:
. .
3. 45p(sure:
. .
,. P!" %*$%" S! -" !r#. Anamnesis &SAMP64'
S &Signs and S/mpt(ms'
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.
A &Allergies'
.
M &Medi)ati(ns'
.
.P &Pertinent Medi)al ist(r/'..
6 &6ast Meal'
4 &47ents'
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-. Pemeriksaan 8isik:Keadaan *mum:
Kesadaran:.9ital sign: TD : . ! : .. !! : .. Suhu : ..
a. Kepala"nspeksi: .
..........
..................................................................................................................
..................Palpasi: ..
..........
..................................................................................................................
.................... b. Telinga
"nspeksi:
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.Palpasi:.
..........
....................
). Mata"nspeksi:.
..........
..................................................................................................................
....................Palpasi:
..............................d. Mulut dan Gigi
"nspeksi:.
..........
..................................................................................................................
...................Palpasi:.
..........
....................e. idung
"nspeksi:.
..........
..................................................................................................................
....................Palpasi: .
..........
.................
+. 6eher:
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"nspeksi:
Palpasi:
.............................g. Dada dan paru
"nspeksi: .
..........
..................................................................................................................
..................................................................................................................
...................Palpasi:.
..........
..................................................................................................................
..................Perkusi:.
............................................................................................................................
.................Auskultasi: .
..........
..................................................................................................................
....................h. antung
"nspeksi:.
..........
..................................................................................................................
....................Palpasi:.
..........
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..................................................................................................................
....................Perkusi:.
..........
..................................................................................................................
.................Auskultasi:.
..........
..................................................................................................................
...................i. Abd(men
"nspeksi:.
..........
..................................................................................................................
..................Auskultasi: .
..........
..................................................................................................................
....................Palpasi:
.
..........
..................................................................................................................
....................Perkusi:.
..........
..................................................................................................................
.................... j. Genetalia
.
..........
......
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k. 4kstremitas 4kstremitas Atas
Kanan:.
....
..........
....Kiri:.
....
............................................................................................................
................ 4kstremitas ,awah
Kanan:.
........
.......
....
...Kiri:.
..
...................................................................................................................
0. Pengkajian 8ungsi(nala. Oksigenasi
Sebelum sakit:
...
...
..Saat sakit:..
...
..
...
..
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b. %utrisi dan 1airan
Keterangan Sebelum sakit Saat sakitMakan 8rekuensi enis makananMinum 8rekuensi enis minuman
Keterangan:...
.
....). 4liminasi
,A,
Keterangan Sebelum sakit Saat sakitaktu
8rekuensi
arnaK(nsistensi
,AK
Keterangan Sebelum sakit Saat sakit8rekuensi
arnaumlah
Keterangan:
.
.d. Term(regulasi
Sebelum sakit:
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....
Saat sakit:
.....
..e. Psik(s(sial &Stress; K(ping; dan K(nsep Diri'
Sebelum sakit:
...
...
..Saat sakit:
..
.
....+. !asa Aman dan %/aman
Sebelum sakit:
...
..
.................................................Saat sakit:
...
...
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...
.
g. "stirahat Tidur Sebelum sakit:
...
....Saat sakit:
...
..
.
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D. P!+!r$ &%%" P!"-"*%"ari$ Tanggal : ..
enis Pemeriksaan asil Satuan %ilai %(rmal Keterangan
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E. T!r% $
enis Terapi D(sis !ute "ndikasi < 1ara Kerja K(ntraindikasi 4+ek Samping
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F. A"%/$&% D%#%
%( Data Masalah 4ti(l(gi Diagn(sa TTD
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G. P!r!" %"%%"
%( Tgl$ am D5 Kep "nter7ensiTujuan dan Kriteria asil "nter7ensi TTD
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H. I+ /!+!"#%&$
Tgl$ am %(. D5 "mplementasi !esp(n TTD
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I . E %/-%&$
%( Tgl$ am D5 Keperawatan 47aluasi TTD
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J. Pembahasan
..............................................................................................
......
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.................................................................................................
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.
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