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Oleh :
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NIM ...............................
LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN KEGAWATDARURATAN
PADA KLIEN DENGAN .........................................
DI .................. RUMAH SAKIT PHC
SURABAYA
Tanggal .............. s/d ..................
Oleh :
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NIM ...............................
Mengetahui,
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 ....................................................................................................................................... ..
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Riwayat
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Kejadian
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Riwayat
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Penyakit Dahulu ..................................................................................................................................... ....
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Riwayat Alergi
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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 : ..................................................................................................................... ...
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Masalah
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Keperawatan
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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
Masalah
Keperawatan
Neurologi
Masalah
Keperawatan
Integumen
Masalah
Keperawatan
Abdomen
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
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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
: ............................................................................................
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Gangguan neurologi lain : ............................................................................................
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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,
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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 : .
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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
: .
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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
Tujuan dan
Kriteria Hasil
Tindakan
Evaluasi
RENCANA KEPERAWATAN
No.
Analisa Data
dan Masalah Keperawatan
Intervensi
Waktu
Tgl/jam
Tindakan
TT
Waktu
Tgl/jam
Catatan Perkembangan
(SOAP)
TT