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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
1
PRAKTIK GAWAT DARURAT
PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA
PENGKAJIAN KEPERAWATAN RUANG ICU
Nama Perawat : ............................................................................
Tanggal Pengkajian : ............................................................................
Jam pengkajian : ............................................................................
A. Biodata :
1. Pasien
Nama : ……………………………………………
Umur : ……………………………………………
Agama : ……………………………………………
Pendidikan : ……………………………………………
Pekerjaan : ……………………………………………
Status Pernikahan : ……………………………………………
Alamat : ……………………………………………
……………………………………………
Tanggal masuk RS : …………………………………………
Jam masuk RS : …………………………………………
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
2
Diagnosa Medis : …………………………………………
2. Pasien
Nama : ……………………………………………
Umur : ……………………………………………
Agama : ……………………………………………
Pendidikan : ……………………………………………
Pekerjaan : ……………………………………………
Status Pernikahan : ……………………………………………
Alamat : ……………………………………………
……………………………………………
Hubungan dengan klien : …………………………………………..
B. Alasan Masuk RS
………………………………………………………………………
………………………………………………………………………
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C. Keluhan utama
………………………………………………………………………
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
3
D. Riwayat Kesehatan
a. Riwayat Penyakit Sekarang :
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b. Riwayat Penyakit Dahulu :
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c. Riwayat Penyakit Keluarga :
……………………………………………………………………
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
4
……………………………………………………………………
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E. Genogram
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
5
F. Primary Survey
1. Air Way
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2. Breathing
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3. Circulation
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
6
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4. Disability
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5. Exposure/Environtment
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G. Secondary Survey
1. Kepala :
a. Kulit : ................................................................................
b. Rambut : ................................................................................
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
7
c. Muka : ................................................................................
d. Mata :
1) Konjungtiva : ....................................................................
2) Sclera : ....................................................................
3) Bentuk Pupil : ....................................................................
4) Ukuran Pupil : ....................................................................
5) Reflek Pupil : ....................................................................
6) Palpebra : ....................................................................
7) Lensa : ....................................................................
8) Visus : ....................................................................
2. Hidung : ................................................................................
3. Mulut : ................................................................................
4. Gigi : ................................................................................
5. Bibir : ................................................................................
6. Telinga : ................................................................................
7. Leher : ................................................................................
8. Tenggorokan : .............................................................................
9. Dada : .............................................................................
a. Pulmo
Inspeksi : .............................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
8
Auskultasi : ........................................................................
b. Cor
Inspeksi : .............................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
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Auskultasi : ........................................................................
10. Abdomen
Inspeksi : .............................................................................
Auskultasi : ........................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
11. Punggung
Inspeksi : .............................................................................
Palpasi : .............................................................................
12. Genetalia
1) Pria : .............................................................................
.............................................................................
2) Perempuan : .........................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
9
13. Rectum : ................................................................................
14. Ektremitas
1) Atas : .............................................................................
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2) Bawah : .............................................................................
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H. Basic Promoting physiology of Health
1. Aktivitas dan latihan
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
10
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2. Tidur dan istirahat
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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3. Kenyamanan dan nyeri
a. Sebelum Sakit
DS : .....................................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
11
b. Selama Sakit
Data Subyektif
Provocatif : ...................................................................
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Paliatif : ...................................................................
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Quality : ...................................................................
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Severity : ...................................................................
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Time : ...................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
12
DO : .....................................................................................
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4. Nutrisi
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
13
5. Cairan, Elektrolit dan Asam Basa
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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6. Oksigenasi
a. Sebelum Sakit
DS : .....................................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
14
.....................................................................................
b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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7. Eliminasi Fekal/Bowel
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
15
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DO : .....................................................................................
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8. Eliminasi urin
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
16
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9. Sensori, persepsi dan kognitif
a. Sebelum Sakit
DS : .....................................................................................
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b. Selama Sakit
DS : .....................................................................................
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DO : .....................................................................................
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
17
I. Psiko sosio budaya Dan Spiritual
1. Psikologis
a. Perasaan klien setelah mengalami masalah ini adalah
………………………………………………………………
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b. Cara mengatasi perasaan tersebut
………………………………………………………………
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c. Rencana klien setelah masalah terselesaikan adalah
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
18
d. Jika rencana klien tidak dapat diselesaikan maka :
………………………………………………………………
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e. Pengetahuan klien tentang masalahah/penyakit yang ada :
………………………………………………………………
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2. Sosial :
a. Aktivitas atau peran di masyarakat adalah :
………………………………………………………………
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b. Kebiasaan lingkungan yang tidak disukai adalah :
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
19
c. Cara mengatasinya:
………………………………………………………………
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d. Pandangan klien tentang aktifitas sosial dilingkungannya :
….……………………………………………………………
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3. Budaya :
a. Budaya yang diikuti klien adalah:
………………………………………………………………
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b. Kebudayaan yang dianut merugikan kesehatannya:
………………………………………………………………
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
20
4. Spiritual :
a. Aktivitas ibadah sehari-hari
………………………………………………………………
………………………………………………………………
………………………………………………………………
b. Kegiatan keagamaan yang biasa dilakukan
………………………………………………………………
………………………………………………………………
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c. Keyakinan klien tentang peristiwa/masalah kesehatan yang
sekarang sedang dialami :
………………………………………………………………
………………………………………………………………
………………………………………………………………
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Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
21
J. Pemeriksaan Penunjang
(Hasil pemeriksaan laboratorium,radiology, EKG,EEG dll)
Jenis Pemeriksaan : ………………
Hari/Tanggal : ………………
NO JENIS PEMERIKSAAN NILAI NORMAL HASIL INTERPRETASI
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
22
K. Terapi Medis
No Nama Terapi Dosis Fungsi
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
23
ANALISA DATA
Nama klien : ………………………………...
Umur :…………………………………
Ruang Rawat :…………………………………
No. Register :………………………………...
Diagnosa Medis :………………………………...
Alamat :…………………………………
PRAKTIK KLINIK KEBUTUHAN DASAR MANUSIA
PROGRAM STUDI S-1 ILMU KEPERAWATAN
UNIVERSITAS RESPATI YOGYAKARTA
TGL/JAM DATA FOKUS ETIOLOGI PROBLEM
PRAKTIK GAWAT DARURAT
PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
24
RE
NC
AN
A T
IND
AK
AN
Nam
a k
lien
:…………………………………………
No. R
egis
ter
:……………………………………
..……
Um
ur
:…………………………………………
D
iagn
osa
Medis
:…………………………………………
..
Ru
an
g
:…………………………………………
Ala
mat
:…………………………………………
..
No
Dia
gn
osa
Ke
pera
wat
an
Tu
juan &
Kri
teri
a H
asil
Inte
rven
siR
asi
on
alis
asi
Nam
a/T
TD
PR
AK
TIK
KL
INIK
KE
BU
TU
HA
N D
ASA
R M
AN
USIA
PR
OG
RA
M S
TU
DI
S-1
IL
MU
KE
PE
RA
WA
TA
N
UN
IVE
RSIT
AS
RE
SPA
TI Y
OG
YA
KA
RTA
Buku Panduan Umum
Praktik Klinik Gawat Darurat
Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)
25
No
.Dx
Tan
ggal
Jam
Imple
me
ntas
iE
valu
asi
CA
TA
TA
N P
ER
KE
MB
AN
GA
N
Nam
a k
lien
:…………………………………………
No. R
egis
ter
:……………………………………
..……
Um
ur
:…………………………………………
D
iagn
osa
Medis
:…………………………………………
..
Ru
an
g
:…………………………………………
Ala
mat
:…………………………………………
..
Nam
a/T
TD
PR
AK
TIK
KL
INIK
KE
BU
TU
HA
N D
ASA
R M
AN
USIA
PR
OG
RA
M S
TU
DI
S-1
IL
MU
KE
PE
RA
WA
TA
N
UN
IVE
RSIT
AS
RE
SPA
TI Y
OG
YA
KA
RTA
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