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