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Praktik Klinik Gawat Darurat

Program Pendidikan Profesi Ners FIKES Universitas Respati Yogyakarta (Unriyo)

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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 : …………………………………………

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Diagnosa Medis : …………………………………………

2. Pasien

Nama : ……………………………………………

Umur : ……………………………………………

Agama : ……………………………………………

Pendidikan : ……………………………………………

Pekerjaan : ……………………………………………

Status Pernikahan : ……………………………………………

Alamat : ……………………………………………

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Hubungan dengan klien : …………………………………………..

B. Alasan Masuk RS

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C. Keluhan utama

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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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E. Genogram

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F. Primary Survey

1. Air Way

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2. Breathing

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3. Circulation

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

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

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

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2) Perempuan : .........................................................................

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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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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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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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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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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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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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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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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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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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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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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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4. Spiritual :

a. Aktivitas ibadah sehari-hari

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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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J. Pemeriksaan Penunjang

(Hasil pemeriksaan laboratorium,radiology, EKG,EEG dll)

Jenis Pemeriksaan : ………………

Hari/Tanggal : ………………

NO JENIS PEMERIKSAAN NILAI NORMAL HASIL INTERPRETASI

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K. Terapi Medis

No Nama Terapi Dosis Fungsi

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ANALISA DATA

Nama klien : ………………………………...

Umur :…………………………………

Ruang Rawat :…………………………………

No. Register :………………………………...

Diagnosa Medis :………………………………...

Alamat :…………………………………

PRAKTIK KLINIK KEBUTUHAN DASAR MANUSIA

PROGRAM STUDI S-1 ILMU KEPERAWATAN


TGL/JAM DATA FOKUS ETIOLOGI PROBLEM

PRAKTIK GAWAT DARURAT

PROGRAM PENDIDIKAN PROFESI NERS


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