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

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

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





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

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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

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

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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


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


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

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

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

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

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

Thoraks/ Fungsi Pernafasan

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





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

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

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

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

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







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

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





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

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

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

Prioritas Masalah



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

Implementasi





Tanggal, Jam



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






Tanggal, Jam



Paraf(nama perawat)

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

Nama : Budi Setiawan,S.Kep.







…………………….Dx.Medis : …………………….











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


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

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

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

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

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


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





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

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

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

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

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







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

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





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

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

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

Prioritas Masalah



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

Implementasi





Tanggal, Jam



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






Tanggal, Jam



Paraf(nama perawat)

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

Nama : Raudhatul Jannah,S.Kep.







…………………….Dx.Medis : …………………….











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


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

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

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

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

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


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





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

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

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

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

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







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

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

Prioritas Masalah



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

Implementasi





Tanggal, Jam



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






Tanggal, Jam



Paraf(nama perawat)

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

Form Igd Askep

Documents

Transcript of Form Igd Askep