Format Pengkajian Gadar UGD
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Transcript of Format Pengkajian Gadar UGD
LAPORAN KASUS ASUHAN KEPERAWATAN KEGAWATDARURATAN PADA KLIEN DENGAN ......................................... DI .................. RUMAH SAKIT PHC SURABAYATanggal .............. s/d ..................
Oleh : _________________________ NIM ...............................
PROGRAM STUDI PENDIDIKAN PROFESI NERS SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA TA. 2011/2012
LEMBAR PENGESAHAN ASUHAN KEPERAWATAN KEGAWATDARURATAN PADA KLIEN DENGAN ......................................... DI .................. RUMAH SAKIT PHC SURABAYATanggal .............. s/d ..................
Oleh : _________________________ NIM ...............................
Mengetahui, Penguji Pendidikan
Surabaya, ................ 20..... Penguji Lahan
______________________
______________________
PENGKAJIAN KEPERAWATAN KEPERAWATAN KEGAWATDARURATAN STIKES HANG TUAH SURABAYA
Nama mahasiswa Tgl/jam pengkajian Tgl/jam MRS Ruangan
: : : :
........................................ ........................................ ........................................ ........................................
Nama pasien Umur pasien Jenis kelamin No. RM Diagnosa medis
: : : : :
........................................ ........................................ ........................................ ........................................ ........................................ ........................................
RIWAYAT KEPERAWATAN Keluhan Utama ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Riwayat ....................................................................................................................................... .. Kejadian ..................................................................................................................................... .... ................................................................................................................................... ...... ................................................................................................................................. ........ ............................................................................................................................... .......... ............................................................................................................................. ............ ........................................................................................................................... .............. ......................................................................................................................... ................ ....................................................................................................................... .................. ..................................................................................................................... Riwayat ....................................................................................................................................... .. Penyakit Dahulu ..................................................................................................................................... .... ................................................................................................................................... ...... ................................................................................................................................. ........ ............................................................................................................................... Riwayat Alergi ....................................................................................................................................... .. ..................................................................................................................................... Keadaan Umum O baik O sedang O lemah BB : kg TB : cm Kesadaran O compos mentis O delirium O sopor O somnolen O koma O alert O verbal O pain O unrespon GCS : E V M Vital Sign Nadi : /menit Suhu : C RR : /menit TD : mmHG Airway O paten O obstruksi Jelaskan : ..................................................................................................................... ... .................................................................................................................................... ..... .................................................................................................................................. Masalah ....................................................................................................................................... .. Keperawatan ..................................................................................................................................... .... ................................................................................................................................... Breathing Pergerakan dada : O simetris O asimetris Penggunaan otot bantu nafas : O tidak ada O ada Jelaskan, ... Suara nafas : O vesikuler O bronkovesikuler Suara nafas tambahan : O tidak ada O ronchi O rales O stridor
O wheezing Batuk : O tidak ada O ada, O produktif O tidak produktif Keluhan sesak nafas : O tidak ada O ada Irama pernafasan : O reguler O ireguler Jelaskan, ... Alat bantu nafas : O tidak ada O ada Jenis : Aliran : lpm ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Akral : O hangat O kering O merah O dingin O basah CRT : O < 2 detik O > 2 detik Edema : O tidak ada O ada
Masalah Keperawatan Circulation
Masalah Keperawatan Neurologi
Masalah Keperawatan Integumen
Irama jantung : O reguler O ireguler Perdarahan : O tidak ada O ada Jenis : . Terpasang CVP : O tidak O ya Nilai CVP O normal O meningkat O menurun ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Pupil : O isokor O anisokor O reflek cahaya : / Ukuran pupil : O normal O midriasis O pin point O meiosis O Lain-lain, Jelaskan : Nyeri : O tidak ada O ada P : Q : R : S : T : Reflek patologi : ............................................................................................ ....................................................................................................................................... Gangguan neurologi lain : ............................................................................................ ....................................................................................................................................... ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Luka bakar : O tidak ada O ada Presentasi luka bakar : Turgor kulit : O baik O sedang O jelek Warna mukosa kulit : Luka dekubitus : O tidak ada O ada Grade,
Masalah Keperawatan Abdomen
....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Frekuensi peristaltik usus : O tidak ada O normal O meningkat O menurun Mual : O tidak ada O ada Emesis : O tidak ada O ada Gangguan eliminasi : O tidak ada O ada
Masalah Keperawatan Perkemihan
Masalah Keperawatan Tindak Lanjut
Jelaskan : . ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Terpasang kateter : O tidak O ya Jenis, . Produksi urin : O normal O poliuri O oliguri O anuria (< 100 cc/hari) Jelaskan : . Masalah perkemihan : O tidak ada O ada Jelaskan : . ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... O KRS O MRS O PP O DOA O Operasi O Pindah O Lain-lain,
PEMERIKSAAN PENUNJANG Jenis pemeriksaan Jam Lab / Foto / ECG / Lain-lain
Hasil
PEMBERIAN TERAPI Jam Tindakan / Medikasi
Keterangan
PERAWATAN INTENSIF Jam TD RR HR Suhu CVP SPO2 Input Output Medikasi (mmHg) (x/menit) (x/menit) (C) (cmH2O) (%) (cc) (cc) obat
TINDAKAN KEPERAWATAN Waktu Analisa data dan Masalah Keperawatan Tujuan dan Kriteria Hasil Tindakan Evaluasi
RENCANA KEPERAWATAN No. Analisa Data dan Masalah Keperawatan Tujuan Dan Kriteria Hasil Intervensi
TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN No. Waktu Tgl/jam Tindakan TT Waktu Tgl/jam Catatan Perkembangan (SOAP) TT