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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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