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FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Nama/NIM : Herry Setiawan,S.Kep. / I1B108227Kelompok : C Ners Muda UNLAMRuangan : Instalasi Gawat Darurat (IGD) RSUD Ulin BanjarmasinTanggal Praktik : …………………………… Tanggal Pengkajian : …………….….
Identitas PasienNama : ……………………. Suku : …………………….Umur : ……………………. Agama : …………………….Jenis Kelamin : Laki / Perempuan Tgl.MRS : …………………….Pendidikan : ……………………. No.RMK : …………………….Alamat : …………………….
…………………….Dx.Medis : …………………….
…………………….Pengkajian PrimerKeluhan Utama
…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Sekarang
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Dahulu
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...PQRST (apabila ada nyeri)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
A……………………………………………………………………………………….……………………………………………………………………………………….
B……………………………………………………………………………………….……………………………………………………………………………………….……………………………………………………………………………………….
C……………………………………………………………………………………….……………………………………………………………………………………….……………………………………………………………………………………….
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Pengkajian SekunderTanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C
Pengkajian Head to ToeKeadaan Umum ……………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Kepala dan Rambut …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Penglihatan ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Hidung ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Telinga ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Mulut dan Gigi ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Leher ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Thoraks/ Fungsi ……………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Pernafasan ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Abdomen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Ekstrimitas …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Intergumen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
No. Data Penyebab Masalah
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Prioritas Masalah
No. Masalah KeperawatanTanggal Paraf
(nama perawat)Ditemukan Teratasi
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Implementasi
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Tindakan Keperawatan Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….
Catatan Perkembangan
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Catatan Perkembangan(SOAPIE)
Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….
Tindakan Resusitasi
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
No Tanggal, jam Tindakan Resusitasi Keterangan
………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..
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Discharge Planning
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….
Nama : Rizani Pahmi,S.Kep.
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
NIM : I1B108239Kelompok : C Ners Muda UNLAMRuangan : Instalasi Gawat Darurat (IGD) RSUD Ulin BanjarmasinTanggal Praktik : ……………………………….Tanggal Pengkajian : ……………………………….
Identitas PasienNama : ……………………. Suku : …………………….Umur : ……………………. Agama : …………………….Jenis Kelamin : Laki / Perempuan Tgl.MRS : …………………….Pendidikan : ……………………. No.RMK : …………………….Alamat : …………………….
…………………….Dx.Medis : …………………….
…………………….Pengkajian PrimerKeluhan Utama
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Sekarang
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Dahulu
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...PQRST (apabila ada nyeri)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Pengkajian Sekunder
FORMAT ASUHAN KEPERAWATAN
STASE 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 …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Penglihatan ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Hidung ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Telinga ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Mulut dan Gigi ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Leher ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Thoraks/ Fungsi Pernafasan
…………………………………………………………………………………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Abdomen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Ekstrimitas …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Intergumen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data
No. Data Penyebab Masalah
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Prioritas Masalah
No. Masalah KeperawatanTanggal Paraf
(nama perawat)Ditemukan Teratasi
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Implementasi
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Tindakan Keperawatan Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….
Catatan Perkembangan
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Catatan Perkembangan(SOAPIE)
Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….
Nama : Budi Setiawan,S.Kep.
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
NIM : I1B108203Kelompok : C Ners Muda UNLAMRuangan : Instalasi Gawat Darurat (IGD) RSUD Ulin BanjarmasinTanggal Praktik : ……………………………….Tanggal Pengkajian : ……………………………….
Identitas PasienNama : ……………………. Suku : …………………….Umur : ……………………. Agama : …………………….Jenis Kelamin : Laki / Perempuan Tgl.MRS : …………………….Pendidikan : ……………………. No.RMK : …………………….Alamat : …………………….
…………………….Dx.Medis : …………………….
…………………….Pengkajian PrimerKeluhan Utama
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Sekarang
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Dahulu
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...PQRST (apabila ada nyeri)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Pengkajian Sekunder
FORMAT ASUHAN KEPERAWATAN
STASE 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 …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Penglihatan ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Hidung ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Telinga ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Mulut dan Gigi ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Leher ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Thoraks/ Fungsi Pernafasan
…………………………………………………………………………………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Abdomen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Ekstrimitas …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Intergumen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data
No. Data Penyebab Masalah
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Prioritas Masalah
No. Masalah KeperawatanTanggal Paraf
(nama perawat)Ditemukan Teratasi
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Implementasi
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Tindakan Keperawatan Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….
Catatan Perkembangan
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Catatan Perkembangan(SOAPIE)
Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….
Nama : Raudhatul Jannah,S.Kep.
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
NIM : I1B108234Kelompok : C Ners Muda UNLAMRuangan : Instalasi Gawat Darurat (IGD) RSUD Ulin BanjarmasinTanggal Praktik : ……………………………….Tanggal Pengkajian : ……………………………….
Identitas PasienNama : ……………………. Suku : …………………….Umur : ……………………. Agama : …………………….Jenis Kelamin : Laki / Perempuan Tgl.MRS : …………………….Pendidikan : ……………………. No.RMK : …………………….Alamat : …………………….
…………………….Dx.Medis : …………………….
…………………….Pengkajian PrimerKeluhan Utama
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Sekarang
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Dahulu
…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...PQRST (apabila ada nyeri)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Pengkajian Sekunder
FORMAT ASUHAN KEPERAWATAN
STASE 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 …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Penglihatan ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Hidung ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Telinga ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Mulut dan Gigi ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Leher ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Thoraks/ Fungsi Pernafasan
…………………………………………………………………………………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Abdomen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Ekstrimitas …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Intergumen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data
No. Data Penyebab Masalah
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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Prioritas Masalah
No. Masalah KeperawatanTanggal Paraf
(nama perawat)Ditemukan Teratasi
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Implementasi
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Tindakan Keperawatan Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….
Catatan Perkembangan
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanggal, Jam
Diagnosa Keperawatan
Catatan Perkembangan(SOAPIE)
Paraf(nama perawat)
…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….