Flu + batuk- Obat flu 3x1- Amok - Dexa - Cloramp 3x2

Asthma- Teopilin 3x1- Ambroksol - Dexa/pred- Amox

Migren/pusing- Asmet 3x1- Luminal 1x1- Vit.- Antasida

Hypertensi- Amlodipin 1x1- Catopril 2x1- Furosemid 1x1- Asmet /sanmol 3x1

Sakit menelan - Sanmol 3x1- Metilpred 3x1- Amok 3x2- Vit

Pusing+lemah- Paraset 3x1- Antasida- Ranitidin- Vit 1x1

Hypertensi+jantung- Ukur kolesterol- Amlodipin 1x1- Furosemid 1x1- Kalium 1x1

Sariawan - Albotik oles- Amok 3x1- Dexa

Pusing+nyeri kepala- Histigo 3x1- Mixalgin 3x1- Luminal 1x1- Antasida 3x1

Gangguan telinga- Amok 3x1- Kotri 2x2- Analgetik 3x1

Types +demam- Sanmol 3x1- Ibu prop - Kloramp 3x2- Amok- Antasida

Nyeri perut + kembung- Mixalgin 3x1- Spasminal 3x1- Ranitidin 2x1

Gastritis - Adimag 3x1- Omeprazol 1x1- Amoxilin 3x1

Diare/mencret- Obat diare 3x2- Kotri/cipro 2x2- Metro 3x1- Metoklopamid

Kolik nyeri pd perut kanan- Spasminal 3x1- Omeperazol 2x1- Ranitidin 3x1- Natrium dik

Menstruasi berlebih- Analgetik 3x1- Vit- Obat KB

DM- Mefermin 3x1- Glibenklamid 2x1- Metoklopamid 3x1

Cacar- Sanmol 3x1- Sipro 2x1- Aciklopir 3x1- Vit.B1 3x1

Nyeri sendi- Alloprinol 3x1- Ibu prof 3x1- Mixalgin 3x1- Dexa 3x1

Uretritis =kentrik- Cipro 2x1- Kotri 3x1- prednison 3x1- antasida 3x1

Keputihan- metro 3x1- sipro 2x1- anti jamur 3x1

BLANKO PENGKAJIAN ASUHAN KEPERAWATAN KEGAWAT DARURATAN DI RUANG IGD

I. PENGKAJIAN

A. IDENTITAS

Nama : ........................................................

Umur : ........................................................

Jenis kelamin : ........................................................

Alamat : ........................................................

Suku/Bangsa : .......................................................

Pekerjaan : .......................................................

Agama : ......................................................

TGL MRS : .....................................................

NO RM : ......................................................

Diagnosa : .....................................................

B. RIWAYAT KEPERAWATAN (NURSING HISTORY)

1. Alasan dirawat /MRS : ......................................................

2. Riwayat Penyakit Sekarang : .........................................................

3. Riwayat penyakit sebelumnya : ................................................

C. OBSERVASI DAN PEMERIKSAAN FISIK

1. Keadaan umum : ........................................................

2. Kesadaran : .........................................................

3. Vital sign

S : .....................

N : ......................

RR : ......................

TD : .....................

2. Pemeriksaan Fisik ( body of system )

B1 : BRETHING : ........................................

B2 : BRAIN : ........................................

B3 : BLOOD : ........................................

B4 : BLADDER : ........................................

B5 : BOWEL : .......................................

B6 : BONE : .......................................

D. PEMERIKSAAN PENUNJANG

1. Tanggal pemeriksaan :..........................

2. Hasil di Uraikan : .........................

a. Darah

b. Photo Rontgen

c. CT Scan

d. dll

E. TERAPHY

II. DIAGNOSA KEPERAWATAN

A. ANALISA DATA

NO DATA PENYEBAB MASALAH

B. RUMUSAN DIAGNOSA KEPERAWATAN

1. ....................................

2. ....................................

3. ....................................

4. DST

III. INTERVENSI

NO HR/TGL TUJUAN DAN KRETERIA HASIL INTERVENSI RASIONAL

IV.IMPLEMENTASI

TGL DX.KEP JAM IMPLEMENTASI RESPON HASIL TTD

IV.EVALUASI (CATATAN PERKEMBANGAN/SOAP )

HR/TGL/JAM NO.DX S O A P TTD