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RS ROEMANI MUHAMMADIYAH SEMARANG
NO RM : JENIS KELAMIN : NAMA : TANGGAL LAHIR : ALAMAT :
Rujukan : Laki –laki
Tanggal : DIAGNOSA KEPERAWATAN : Bersihan jalan nafas tidak efektif (00031) Pola nafas tidak efektif (00032) Kerusakan pertukaran gas (00030) Resiko inefektif perfusi jaringan cerebral (00201) Nyeri akut (00132) Penurunan kapasitas adaptif intrakranial (00049) Penurunan curah jantung (00029) ............................................................................... ...............................................................................
Perempuan
Jam : RENCANA INTERVENSI: Manajemen Air Way Air Way Suctioning Manajemen asam basa Promosi peningkatan perfusi jaringan cerebral Manajemen nyeri Manajemen syok Monitoring tanda-tanda vital dan kesadaran Manajemen lingkungan Pendidikan kesehatan ......................................................................... .........................................................................
TINDAKAN KEPERAWATAN /KOLABORASI Cardiopulmonal THT /Mata ........................................................................... Pulse Oximetri (SpO2) Irigasi Mata ........................................................................... Intubasi Irigas Telinga ........................................................................... RJP Ambil Corpal di telinga ........................................................................... Cardioversion/ DC Syok Ambil Corpal di ........................................................................... Pacemaker Eksternal hidung ........................................................................... Pemasangan CVP ........................................................................... Tindakan Obsgyn Trauma / Bedah TINDAKAN PENUNJANG Membantu partus Cervical Coolar Cek Lab.............................................................. Periksa Gyn Immobilisasi tulang Rongen.............................................................. Dopler, CTG, USG belakang CT Scan.............................................................. Pasang Tampon Gips .......................................................................... Lain-lain........ Immobilisasi bahu TINDAKAN LAIN Immobilisasi kaki O2 .............l/m binasal/ NRM/RM/CPAP Perawatan luka Rekam EKG/Monitor EKG Persiapan /jahit luka Nebulizer Balutan Pasang Infus Perawatan luka bakar Injeksi/Syiringe Pump Selang dada/WSD Tranfusi Darah NGT : ukuran............... Bilas Lambung : Oral Kondom/dower kateter Restrain/ Pengaman EVALUASI KEPERAWATAN/TINDAK LANJUT Perawat Jaga ........................................................................................................................ ....................................................................................................................... ....................................................................................................................... (...............................) ....................................................................................................................... Tada tangan & Nama lengkap
TINDAKAN LANJUTAN
Tgl. Keluar IRD :
JAM : Dipulangkan, Kontrol Poliklinik Pulang Paksa / menolak Tindakan Pindah RS Atas Permintaan: Dirujuk Ke: Masuk RS, di: Melarikan Diri Meninggal
Kondisi keluar IRD Membaik Tetap Memburuk Kritis Meninggal DOKTER
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