Form Igd Askep

FORMAT ASUHAN KEPERAWATAN

STASE KRITIS DAN GAWAT DARURAT

PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS LAMBUNG MANGKURAT

Nama/NIM : Herry Setiawan,S.Kep. / I1B108227Kelompok : C Ners Muda UNLAMRuangan : Instalasi Gawat Darurat (IGD) RSUD Ulin BanjarmasinTanggal Praktik : …………………………… Tanggal Pengkajian : …………….….

Identitas PasienNama : ……………………. Suku : …………………….Umur : ……………………. Agama : …………………….Jenis Kelamin : Laki / Perempuan Tgl.MRS : …………………….Pendidikan : ……………………. No.RMK : …………………….Alamat : …………………….

…………………….Dx.Medis : …………………….

…………………….Pengkajian PrimerKeluhan Utama

…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Sekarang

…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Dahulu

…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...PQRST (apabila ada nyeri)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...

A……………………………………………………………………………………….……………………………………………………………………………………….

B……………………………………………………………………………………….……………………………………………………………………………………….……………………………………………………………………………………….

C……………………………………………………………………………………….……………………………………………………………………………………….……………………………………………………………………………………….

Pengkajian SekunderTanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C

Pengkajian Head to ToeKeadaan Umum ……………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Kepala dan Rambut …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Penglihatan ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Hidung ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Telinga ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Mulut dan Gigi ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Leher ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Thoraks/ Fungsi ……………………………………………………………………

Pernafasan ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Abdomen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Ekstrimitas …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Intergumen ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...

Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data

No. Data Penyebab Masalah

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Prioritas Masalah

No. Masalah KeperawatanTanggal Paraf

(nama perawat)Ditemukan Teratasi

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Implementasi

Tanggal, Jam

Diagnosa Keperawatan

Tindakan Keperawatan Paraf(nama perawat)

…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….

Catatan Perkembangan

Tanggal, Jam

Catatan Perkembangan(SOAPIE)

Paraf(nama perawat)

…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………………….

Tindakan Resusitasi

No Tanggal, jam Tindakan Resusitasi Keterangan

………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..………………………………………..

……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….……………………………….

Discharge Planning

………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….………………………………………………………………………………………………….

Nama : Rizani Pahmi,S.Kep.

NIM : I1B108239Kelompok : C Ners Muda UNLAMRuangan : Instalasi Gawat Darurat (IGD) RSUD Ulin BanjarmasinTanggal Praktik : ……………………………….Tanggal Pengkajian : ……………………………….

…………………….Dx.Medis : …………………….

…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Riwayat Penyakit Sekarang

…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...PQRST (apabila ada nyeri)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Pengkajian Sekunder

Tanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C