LAPORAN KASUS

ASUHAN KEPERAWATAN KEGAWATDARURATAN

PADA KLIEN DENGAN .........................................

DI .................. RUMAH SAKIT PHC

SURABAYA

Tanggal .............. s/d ..................

Oleh :

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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

SURABAYA

Tanggal .............. s/d ..................

Oleh :

_________________________

NIM ...............................

Mengetahui,

Penguji Pendidikan

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Surabaya, ................ 20.....

Penguji Lahan

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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 : ........................................

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RIWAYAT KEPERAWATANKeluhan Utama ....................................................................................................................................... ..

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...................................................................................................................................Riwayat Kejadian

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.....................................................................................................................Riwayat Penyakit Dahulu

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...............................................................................................................................Riwayat Alergi ....................................................................................................................................... ..

.....................................................................................................................................Keadaan Umum O baik O sedang O lemah BB : kg TB : cmKesadaran 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 : mmHGAirway O paten O obstruksi

Jelaskan : ..................................................................................................................... ....................................................................................................................................... .......................................................................................................................................

Masalah Keperawatan

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...................................................................................................................................Breathing Pergerakan dada : O simetris O asimetris

Penggunaan otot bantu nafas : O tidak ada O adaJelaskan, ...

Suara nafas : O vesikuler O bronkovesikulerSuara 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 adaIrama pernafasan : O reguler O ireguler

Jelaskan, ...Alat bantu nafas : O tidak ada O ada

Jenis : Aliran : lpmMasalah Keperawatan

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...................................................................................................................................Circulation Akral : O hangat O kering O merah O dingin O basah

CRT : O < 2 detik O > 2 detik

Edema : O tidak ada O ada

Irama jantung : O reguler O iregulerPerdarahan : O tidak ada O ada Jenis : .Terpasang CVP : O tidak O ya

Nilai CVP O normal O meningkat O menurunMasalah Keperawatan

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...................................................................................................................................Neurologi Pupil : O isokor O anisokor O reflek cahaya : /

Ukuran pupil : O normal O midriasis O pin point O meiosisO Lain-lain, Jelaskan :

Nyeri : O tidak ada O adaP : Q : R : S : T : Reflek patologi : ...................................................................................................................................................................................................................................Gangguan neurologi lain : ...................................................................................................................................................................................................................................

Masalah Keperawatan

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...................................................................................................................................Integumen Luka bakar : O tidak ada O ada Presentasi luka bakar :

Turgor kulit : O baik O sedang O jelekWarna mukosa kulit : Luka dekubitus : O tidak ada O ada Grade,

Masalah Keperawatan

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...................................................................................................................................Abdomen Frekuensi peristaltik usus : O tidak ada O normal O meningkat O menurun

Mual : O tidak ada O adaEmesis : O tidak ada O adaGangguan eliminasi : O tidak ada O ada

Jelaskan : .Masalah Keperawatan

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...................................................................................................................................Perkemihan 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 adaJelaskan : .

Masalah Keperawatan

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...................................................................................................................................Tindak Lanjut O KRS O MRS O PP O DOA O Operasi O Pindah

O Lain-lain,

PEMERIKSAAN PENUNJANG

Jam Jenis pemeriksaanLab / Foto / ECG / Lain-lain Hasil

PEMBERIAN TERAPIJam Tindakan / Medikasi Keterangan

PERAWATAN INTENSIF

Jam TD(mmHg)RR

(x/menit)HR

(x/menit)Suhu(C)

CVP(cmH2O)

SPO2(%)

Input(cc)

Output(cc)

Medikasiobat

TINDAKAN KEPERAWATAN

Waktu Analisa data dan Masalah KeperawatanTujuan dan

Kriteria Hasil Tindakan Evaluasi

RENCANA KEPERAWATAN

No. Analisa Datadan Masalah Keperawatan Tujuan Dan Kriteria Hasil Intervensi

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No. WaktuTgl/jam Tindakan TTWaktuTgl/jam

Catatan Perkembangan(SOAP) TT