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FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Nama/NIM : ………………………………………………….Kelompok : ………………………………………………….Ruangan : ………………………………………………….Tanggal Praktik : …………………………… Tanggal Pengkajian : …………….….
A. Identitas Pasien Nama : ……………………. Suku : …………………….Umur : ……………………. Agama : …………………….Jenis Kelamin : Laki / Perempuan Tgl.MRS : …………………….Pendidikan : ……………………. No.RMK : …………………….Alamat : …………………….
…………………….Dx.Medis : …………………….
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B. Riwayat Penyakit Keluhan Utama
…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Riwayat Penyakit Sekarang
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Riwayat Penyakit Dahulu
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Riwayat Penyakit Keluarga…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...C. Pemeriksaan Fisik
FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C
Pengkajian Head to ToeKeadaan Umum ……………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Kepala dan Rambut ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Mata ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………….
Hidung …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………..
Telinga ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Mulut dan Gigi ……………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
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Leher ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Thoraks/ Fungsi Pernafasan
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Abdomen ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Genetalia ……………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
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Ekstrimitas …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Intergumen ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Jantung …………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
DATA PENUNJANG
FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...TERAPI
FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
ANALISIS DATA
No. Data Penyebab Masalah
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FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
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FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
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FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
PRIORITAS MASALAH
No. Masalah KeperawatanTanggal Paraf
(nama perawat)Ditemukan Teratasi
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FORMAT ASUHAN KEPERAWATAN
KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
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