Format Pengkajian Gadar UGD

LAPORAN KASUS ASUHAN KEPERAWATAN KEGAWATDARURATAN PADA KLIEN DENGAN ......................................... DI .................. RUMAH SAKIT PHC SURABAYA Tanggal .............. s/d ..................

Oleh : _________________________ NIM ...............................

PROGRAM STUDI PENDIDIKAN PROFESI NERS SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA TA. 2011/2012

LEMBAR PENGESAHAN ASUHAN KEPERAWATAN KEGAWATDARURATAN PADA KLIEN DENGAN ......................................... DI .................. RUMAH SAKIT PHC SURABAYA Tanggal .............. s/d ..................

Oleh : _________________________ NIM ...............................

Mengetahui,

Surabaya, ................ 20.....

Penguji Pendidikan

Penguji Lahan

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PENGKAJIAN KEPERAWATAN KEPERAWATAN KEGAWATDARURATAN STIKES HANG TUAH SURABAYA

Nama mahasiswa Tgl/jam pengkajian Tgl/jam MRS Ruangan

: : : :

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Nama pasien Umur pasien Jenis kelamin No. RM Diagnosa medis

: : : : :

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RIWAYAT KEPERAWATAN Keluhan Utama ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Riwayat ....................................................................................................................................... .. Kejadian ..................................................................................................................................... .... ................................................................................................................................... ...... ................................................................................................................................. ........ ............................................................................................................................... .......... ............................................................................................................................. ............ ........................................................................................................................... .............. ......................................................................................................................... ................ ....................................................................................................................... .................. ..................................................................................................................... Riwayat ....................................................................................................................................... .. Penyakit Dahulu ..................................................................................................................................... .... ................................................................................................................................... ...... ................................................................................................................................. ........ ............................................................................................................................... Riwayat Alergi ....................................................................................................................................... .. ..................................................................................................................................... Keadaan Umum O baik O sedang O lemah BB : …… kg TB : ……cm Kesadaran O compos mentis O delirium O sopor O somnolen O koma O alert O verbal O pain O unrespon GCS : E …… V …… M …… Vital Sign Nadi : …… × /menit Suhu : …… °C RR : …… × /menit TD : …… mmHG Airway O paten O obstruksi Jelaskan : ..................................................................................................................... ... .................................................................................................................................... ..... .................................................................................................................................. Masalah ....................................................................................................................................... .. Keperawatan ..................................................................................................................................... .... ................................................................................................................................... Breathing Pergerakan dada : O simetris O asimetris Penggunaan otot bantu nafas : O tidak ada O ada Jelaskan, …………………………………………... Suara nafas : O vesikuler O bronkovesikuler Suara nafas tambahan : O tidak ada O ronchi O rales O stridor

O wheezing Batuk

Masalah Keperawatan Circulation

: O tidak ada O ada, O produktif O tidak produktif Keluhan sesak nafas : O tidak ada O ada Irama pernafasan : O reguler O ireguler Jelaskan, …………………………………………... Alat bantu nafas : O tidak ada O ada Jenis : …………………… Aliran : …… lpm ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Akral : O hangat O kering O merah O dingin O basah CRT : O < 2 detik O > 2 detik Edema

Masalah Keperawatan Neurologi

Masalah Keperawatan Integumen

Masalah Keperawatan Abdomen

: O tidak ada O ada

Irama jantung : O reguler O ireguler Perdarahan : O tidak ada O ada Jenis : ………………………………. Terpasang CVP : O tidak O ya Nilai CVP O normal O meningkat O menurun ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Pupil : O isokor O anisokor O reflek cahaya : ……/…… Ukuran pupil : O normal O midriasis O pin point O meiosis O Lain-lain, ……………………………………………… Jelaskan : ………………………………………………… Nyeri : O tidak ada O ada P : …………………………………………………………………………………… Q : …………………………………………………………………………………… R : …………………………………………………………………………………… S : …………………………………………………………………………………… T : …………………………………………………………………………………… Reflek patologi : ............................................................................................ ....................................................................................................................................... Gangguan neurologi lain : ............................................................................................ ....................................................................................................................................... ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Luka bakar : O tidak ada O ada Presentasi luka bakar : …………… Turgor kulit : O baik O sedang O jelek Warna mukosa kulit : …………………………………………… Luka dekubitus : O tidak ada O ada Grade, …………

....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Frekuensi peristaltik usus : O tidak ada O normal O meningkat O menurun Mual : O tidak ada O ada Emesis : O tidak ada O ada Gangguan eliminasi : O tidak ada O ada

Masalah Keperawatan Perkemihan

Masalah Keperawatan Tindak Lanjut

Jelaskan : ………….…………………………………… ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... Terpasang kateter : O tidak O ya Jenis, ………………………………. Produksi urin : O normal O poliuri O oliguri O anuria (< 100 cc/hari) Jelaskan : ………….…………………………………… Masalah perkemihan : O tidak ada O ada Jelaskan : ………….…………………………………… ....................................................................................................................................... .. ..................................................................................................................................... .... ................................................................................................................................... O KRS O MRS O PP O DOA O Operasi O Pindah O Lain-lain, …………………………………………………………………………

PEMERIKSAAN PENUNJANG Jenis pemeriksaan Jam Lab / Foto / ECG / Lain-lain

PEMBERIAN TERAPI Jam Tindakan / Medikasi

Hasil

Keterangan

PERAWATAN INTENSIF Jam

TD RR HR Suhu CVP SPO2 Input Output Medikasi (mmHg) (x/menit) (x/menit) (°C) (cmH2O) (%) (cc) (cc) obat

TINDAKAN KEPERAWATAN Waktu

Analisa data dan Masalah Keperawatan

Tujuan dan Kriteria Hasil

Tindakan

Evaluasi

RENCANA KEPERAWATAN No.

Analisa Data dan Masalah Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN No.

Waktu Tgl/jam

Tindakan

TT

Waktu Tgl/jam

Catatan Perkembangan (SOAP)

TT