BAGIAN KEPERAWATAN GAWAT DARURAT FAKULTAS KEPERAWATAN UNIVERSITAS ANDALAS EVALUASI AKHIR SIKLUS FORMAT PENGKAJIAN ICU/CVCU Rim Dai Marta, + MAB 2042. Nama Mahasiswa No BP Tanggal Tempat Nama Pasion : ‘Tanggal masuk Ri 1. Pengkajian Primer saat ini A: Peenapasan Abani oleh Ventilator Meiutus ttareostons , Sexret C4) Servet berwana Kaning heshiotans Repler hatuk C4), Telaw ada Srenns dan Adar ace gacqting- B: Pasien Gaesek Napas ,Yertnat adanyp Takraksd dinding dade . Renetacan Suping iduns (-). Pemagaran pase dibanty ventilator denean mode Fe Sway . Riwp shor go, Vere. Wiesgen 342, BR a8, Figen #12 Nye 196. Meron ~ 305 E: Guhw paste ML 36:8 « Marja Wea Rou Tiroelewtmis pack, Wher Rarer Luke keangt Camm 4 duoc £ \0eeA yor. bensarne, Riwayat kesehatan saat ini . Hari rawat ICU/CVCU ke pal.YA. IM Beet Aenan eluivin Rutan letaeh sega Ie haw wi Cacien ‘Umur > GTO = tole, mela N= tap efmenat AP -B0 Nad tence tuat aan terator . Atral Aerka hangat. Cet 72 AEH -Mognatinn, camem'r, Stanosts(-), Murore bilir Kena - pif flesadanin sul dinilai kavene pergart Repen raya Hh, Rupr rvoleor n Haat. ican pupil Zmn/zanmn Bilan NYE dengan mrcnggunazar Bes CBerevior ein Scate) =F Way (mentyic) dg chor 4, Assteeenhag (Talk ade pyren)Ayeor | DP dea AS Yer CdS bale Wp sh tolerant) ste 2 KE merylacton Gin X besCare ' i j 4 . i mend beh, i ! Petes ming, oi mora Ree Same fe hdab maa. esa regar CF deme ) Mrantah ©) “Fasien merseul eae Genylan di cher SRI don bercte Copel Member Saye Uden kevet ie Cri Merstuny (OSE 2 mage eS « Olen Dh Indian dtctikes S6h SAMI UA elon LaNgRy man te icu Nn Seed etl tradi i GO CE6udeh 12 herd dP LW) 9 fauynore Medi = Co Weoid 2 Rsk. TWrordertonntI. Pengkajian Sekunder Kepala Inspeksi / Palpasi : Keluhan Mata Ukuran pupil Akomodasi Konjungtiva Palpebra Keluhan Raminat tompale ber tidal ads (esi ttd.l ads berilan Isokor /Unisoker ‘sokor / Unisokor C Hidung dan sinus Inspeksi Pembangkakan Keluhan ‘Mulut dan tenggorok Inspeksi Natal Gontch Geneg Keadaan membran mukosa : #ewr meltom. Me Keluhan saad ode uate Leher Inspeksi /patpasi : .Certorm.., Artec Ketuhan chaps Many Uther cate Orreenne. tegeet ‘Thoraks: Inspeksi 1 Retest diedey, dade Patpasi Perkusi Paru Perkusi Jantung Auskultasi Paru Pola ventilator Deskripsi ventilator : Mie 2: Meare P8 Prvse, 2s. 60 E224 PR 56, Ausikultasi Jantung : Gambaran EKG Sikulasi Frekwensi nadi Tekanan darah sunutubun FEE Suny ekstremitas: .” Sianosis > Bibi kuku . els Me. Pucat :..Turgor ‘Abdomen Me fechorons Inspeksi Gmetss Wut Kanan, bach ade ley Adds ode Colen. Auskultasi Paipasi Perkusi Jenis diet Pengetuaran NGT- . : vs BAB 2 Aisi. Konsistens! feses : (ket BAK 2 Regu, Mette Volume Urin Ekstremitas atas dan bawah Inspeksi EPt 7 2 dene dues ade deg del barjet Masa otot Tonus otot : . et, Kekakuan © .. Keluhan Berat badan :..... Tinggi badan : .. mM. Data Laboratorium MT ag ~ cee Kanna kuin, heutcdat we Pay, . sHamujebin 34 4 + Toke puking. Lt Natron “52 bo 46 7 . ] + Bivens oe b Maton 2 Oe toy ee ¥en + Uinta ® 1 Fens 105 for Gee | eet 25 ation Oe Meo Wo, 26,6 ‘ Towa oe Mew dent 24 Not 2 140 teo2 HO . 1 5 wey “Rewer Ost ke et dec 2° ql - iasil Pemeriksaan Diagnostik lain cen < oe y Be Ue F ue Src 45 —fennen Rapid tar Srey feyah' + 9d eR eye LAC = 2.0 tebe Bu Kee 4 THe 61 b V. Pengobatan Cop etm BAL GF (WY ewe Caen ~ Levopwacyn TY) EUG ee cv Rando 247 WW) + Sauce! Vgrtine) = Melulgaid 3410 () + Heke Breslin = Falbanin = be Quer “Be + diamLEMBAR OBSERVASI a rey "fit ee | aw (Tangosl: is pi tom TTingkat Kesadaran’ | sistem “Ukuran Pupil _ ‘ Neurclegi —“Reaksi Pupil ~ "Sstem * Pomatasan ‘Sistem Kardiovaskuler ‘Suhut Cairan | Mosuk i Cairan | Keluar“Gsi_Praktck Profesi Keperawatan Gawat Darurat vee Fakultas Keperawalan UNAND 2021 FE Woc } i (ke | Terapi Peryinaron gala | esr dan pads deta Rasp Kap eee ! Lt wo eee el | “Tarhat Neaptaome.foramuban | L Vpotalawur adepar Tet Hepat anor aga Peheyeatan seven TSH \ Th.44 Kalatone tena { | teal dikdenger tyroid | | { | i | Masia wt Trex | | | L ! Venison bear unin atelow eo pt sins a, L EE tet we Oe wat ‘oe om tle | "Tetrion talon Naor | VB seeps 4 vee yay Twit Wie Tag cat Top Her i ! T ! oe | aadew! ! ‘Pest (eee ean y Vee Bae ‘wal | | apt Hegnatore Coder I \ we bs pap Tegeinye tnt any ee Abe isan Lage lee Cale EF ow diontyy fume oe — iia Dwi Martha S.ks : Pash [apc " 30413 12082 yet wgous?| Ne i "Gagan Tenagvan Coogan aor FORMAT RENCANA ASUHAN KEPERAWATAN GAWAT DARURAT ms ~ _— Diagnose Keperawatan ‘dan Data Ponuniang ‘Luaran dan Kritora Hast Vearioes Worse — Gea nen leven fame | BYE Hyon 204 ne la el magne | iin nape Haas Wane layin Utensil ange faith gar ~ Ninna rca Ue ‘emis gc dmge) MAE espe Hale F 3 learnt 8 toh mye mee ve . aoe tee eens AEDS Ee eas we " etpag mg be Bae = Geen Mae weer Verte na an = ea ge 2 tates ng ‘wont = Pasir Sudha Yeas fetta an venta Si Interns Fovestnsan Raper — Soren Petar enaaenjme Sealine Sug one nn fe wae nce mp ah tree. ay. junlon fan Seger Panton San Se Letasate Aden! Obie Case nr te Tey . he ea! mina” tape Maks puto Phonets ba pletedWo 2 Diagnose Keperawatan an Data Ponunjang Bentan oor Soar Teas ete teounge dengan jaune ying ter Fehon dtenda’ fegr Wain Ware she at ios Dos Bans ts, ecg + Swans behetihan ~ Spe tonsene fo = Renda: ~ Gaara, Fra myn Watt ula PE 2M heme FORMAT RENCANA ASUAN KEPERAWATAN GAWAT DARURAT Benn ike Spee} Gea dei betalan Hepes. daar wets 226 50 fear Rare MPa par tye woe Wengegt fam ~ Vata Spd, aanarn emp sah § + read tenemos faba “Dagees see dy wlan & “renee tas mew baie byte % “Ronse Yate foe i = Lames Youjaget lente tomy der As dha - 1 2 Beats® Cangen Ledeen A = Paldbwers patio Ip ae 5 SeFORNAT RENCANA ASUHAN KEPERAWATAN GAWAT DARURAT ma —y - — 7 wo Pganosamererawalan gran dan Ker Hi nace | betas Bape teak beliorpn Tigiar Mes 1 Mange bye | Nort , Benji Py geaaive (wee Asnve tmn? begenuce| a acl eae si FA de fans ge ee entire ste ae ates a 2 Wray rege ah nen eet an beans Aus | 12 Womhe Gm Some Yona alot | Tuse peat. 7 Fett mt pend here D an ! = Leh Niyeym yoy Naapron’ 1 Poe et esi : ne ote “Rasen spe i Peehasen aon Mintabe me Ned 8g alot 1 1 Wiilors Gate angers migeaons \ huts min sae ' Poel. : = Sat re 1 1 nepin Bs 4 [deter Pain Sale) + 1 tyes ont 1 RES. aes 1 ! sir dae ade (1) Poy Aes ery[FORMAT RENGANA ASUNAN KEPERAWATAN GAWAT DARURAT no Dingneta Keperawatan ‘dan Data Pesunjang {uatan dan teria Has Intrenet vias Bone Ino dont! Ainge ge! frente ‘oye Sy Fie a sau gyn Wats HPT Prin Le ns rk dey get nn’ eat “ ‘gina nts ae oem Be relink doe lea be fee Teer te wos a sui) tan pov snes “BA Hr te) Wert ots 4 Fe (9) 7 Na ot a C0) Tent aang mnt = Meier Cae cen boas = Voom diverter ‘owe wend i = Sie 36.9% = Coe les gs, 0 homeo Net ta athe Bae Fem Tent Gpanias eRe Bang ween Ee ate w conden ‘hue engi (OB Ge Srnet nor Mentteins te ie a pe: etd Pate eo len, Rerun dene is nis de tain Nac 45 onl em Sena darter Nerds ta YEP fant tees foro We Kolaboonad Peireron fraisFORMAT RENCANA ASUHAN KEPERAWATAN GAWAT DARURAT No” Diagnosa Keperawatan ‘ntervenst Rivas en Sata Perum = iia F Beste Redarten —Gatin Aaicton Renn fosmeom Gh Aetendet dap Gare | Haan ganbetihan is % Yemgon 9 8 ments 35 6 “ Korgtyhen Sourie pa Hote a | Tonge wee opeyen tte Sst ci se LR rates | Towers Leforanten cite fade heyy goers EEN pe nes Tet “ apmor Rai Rebates de hpyin Redurme moe % epantor Saale Aende vite) Setey aise awstats | ae eee Appt ator woe ote He \ me oe ues (role wate = Hangin nee fs Yeh he «Haat et oe Fe gas Rothe een = sear a ma arte gp den ings nok wi eps pai ie 7 te veya pede ae een veges pe bons ~ Vlas asi tae tk iGap Toei ooo rane Fagen pe? FORMAT CATATAN PERKEMBANGAN Wasi “ent Pitan, tone etsinan,dm urge! Gs = Yo 0 Resien ‘age Tate Natngyan ek ~ Gewtenes) Wie ade nate ls rape Fe tena get faba goign OY, = wd JR. plat Agehan danylon : tyres up wep ~ Many seat hey phe Sh 860 Fp. ostay Bryon :FORMAT CATATAN PERKEMBANGAN -L.Dlagnosa Keserawatan 7 Wnplementasi ‘Evaluasi "Dente Sawn Noga = Monier - Sa oe ‘Kiger 6 Moharugen dine Mente Bay! (AE ete, \ foreny das idan Os Gereced Sater Yr Tet nae Bede — Hylan ior ted bray das re te ‘dep raga PAL Gad, Again non thal OS 4 : had Yetaion = Woveirtn Brgge moe ~ Morse ares Vana Fed Gp Eee a Dog Heddy paren : Pe auc bern hen oer ca 1G Yn Aan gateFORMAT CATATAN PERKEMBANGAN Diagnose Keparawatan % Moi amt bd Am Yecalen Girt 24 “eos Iplemontast —Caortiee lds jRadtemtt Fre ene Wether tes Wate Sule Lye meygencleae BS Cece Rain Sumile } Yengbenis® Yope ne ton Uetat ~ Fors anties yy magotant me ~ Faber ater age evaluas! ce Os ates gat Henne Lge ye went Hah deco ' ore maui Bee Sale me & = Nee leet Be Mates Galan Aenotes Pe Mtewen dilegtinFORMAT CATATAN PERKEMBANGAN : Diagnosa vatuasi et gentn tennis evalua! B Neen og! Went eee 2 gente tapas tat - 7 0. oar beget wergir = Be gh Rasy : , = Lave fob op mel fanget ment So a ee ee oy pace = Tales ae ot beer \ ~ Pobete feat aegis ~ We wee «Nee toe Bm am in de Bee Mad ule Souter : Prrwahe lute Rete att Bete deg,FORMAT CATATAN PERKEMBANGAN aqnosa Keperawal T__ implomentasi _Evalvasi Pesiny Tordarson Bier Atautr tube Ben pte Pon & Bory abt Maen Fc ay ly ueoginn Ban ened O2-Parien Manet wane = Nowtor tao aed is! wee owe ne i + Bahai atolae yar = Bia Attn Arg’ Aaa, Hera Pontein grt dame Users sleep hee este BW IY, wey Bo tpe alone a a" y= Mae tt tors ys ern MersonEd Proktek Profesi Keperawatan Gawat Darurat, y 33} Fakultas Keperawatan UNAND 2022 LEMBAR BIMBINGAN PRAKTIK PROFESI KRPERAWATAN GAWAT DARURAT FAKULTAS KEPERAWATAN UNIVERSITAS ANDALAS Nama Mahasiswa Rina Qui Mere No. BP 2 204424. an nnn eda angan | Tanda Tangan | | no. | Hari/Tanggal | Kegiatan /Saran Pembimbing | Mahasispa _ Pembjmbing _/ eee ene een a : ih a Panera £ oelengag! : ‘ ‘ [ ptabeninn ' PR Side ay i { in pom | a «8 hog b. pth anus wee. i fa Pre barks Akg poo [ Mentep 3 59 b tecey - Dadrrt ft paten LB kamts i e . Pern” EM Pone” Ebabney,” + | Lo tur :