ASUHAN KEPERAWATAN

PADA ……….DENGAN……………………………………………………..
DIAGNOSA MEDIS……………..………………
DI INSTALANSI GAWAT DARURAT (IGD) RSROEMANI SEMARANG

DisusununtukMemenuhiTugaspadaPraktikKlinikStaseGawatDarurat
PembimbingKlinik :…………………………..….
PembimbingAkademik :……………………………...
PembimbingAkademik :……………………………...

Oleh:
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PROGRAM S1

DEPARTEMEN ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
SEMARANG
2017
 ASUHAN KEPERAWATAN GAWAT DARURAT

PADA .......................... DI INSTALASI GAWAT DARURAT (IGD)

RS ROEMANI SEMARANG

A. PENGKAJIAN
Dilakukan pada tanggal: ...................................Pukul: ......................................
1. Identitas Pasien
Nama :.................................................................................
Umur : .................................................................................
Jenis kelamin : .................................................................................
Agama : ................................................................................
Status :.................................................................................
Pekerjaan :..................................................................................
Alamat :.................................................................................
Pendidikan :.................................................................................
Suku/Bangsa : ..................................................................................
Tanggal masuk RS : ......................................Pukul: ...............................
No.RM :.................................................................................
Diagnosa medis :..................................................................................
2. Identitas Penanggung Jawab Pasien
Nama : .................................................................................
Umur : ..................................................................................
Jenis kelamin : .................................................................................
Hubungan : .................................................................................
Alamat : ..................................................................................
No. Telepon : .................................................................................
3. Pengkajian Primer
a. Airway :
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b. Breathing :
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c. Circulation :
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d. Disability :
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e. Exposure
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f. Folley catheter
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g. Gastric tube
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 h. Heart monitor
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4. Pengkajian Sekunder
a. Pengkajian SAMPLE
1) Symptom

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2) Allergy

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3) Medication

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4) Past Illnes

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 5) Last Meal

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6) Event

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b. Pemeriksaan Fisik
1) TTV saat pengkajian :
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2) Keadaan Fisik
a) Kepala
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b) Mata
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c) Hidung
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d) Telinga
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e) Mulut
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f) Leher
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g) Thorak
Paru-paru
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Jantung
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h) Abdomen
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i) Genetalia
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 j) Anus
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k) Ekstremitas
Atas
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Bawah
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l) Integumen
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5. Pemeriksaan Penunjang
Jenis Pemeriksaan Hasil Nilai Normal Interpretasi
 6. TerapiMedis

Jenis Terapi Indikasi Kontraindikasi Efek Samping

B. ANALISA DATA
No Data Problem Etiologi
C. PRIORITAS DIAGNOSA KEPERAWATAN
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D. INTERVENSI
Tgl/jam Dx.Kep Tujuan&KriteriaHasil Intervensi
E. IMPLEMENTASI
Tgl/jam No. Dx. Kep Implementasi Evaluasi Formatif Paraf
F. EVALUASI
Tgl/jam Dx. Kep Evaluasi Paraf
 PEMBAHASAN

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 DAFTAR PUSTAKA

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