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(FORMAT RESUME IGD MEDIK)
RESUME KEPERAWATAN PASIEN MEDIK RUANG INSTALASI GAWAT DARURAT SEKOLAH TINGGI ILMU KESEHATAN SARI MULIA BANJARMASIN
I.
II.
IdentitasKlien 1.
Nama
:
2.
JenisKelamin
:
3.
Umur
:
4.
Pendidikan
:
5.
Pekerjaan
:
6.
Alamat
:
7.
Status Perkawinan
:
8.
Agama
:
9.
Suku / Bangsa
:
10. TglMasuk RS
:
11. DiagnosaMedis
:
12. No. RekamMedik
:
13. Tanggal Pengkajian
:
RiwayatPasien 1. KeluhanUtama ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 2. RiwayatPenyakitSekarang ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………….
3. RiwayatPenyakitDahulu ……………………………………………………………………………………… …..…………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………. 4. RiwayatPenyakitKeluarga ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………
III.
Pengkajian Primer / Triase 1. Airway ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 2. Breathing ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………. 3. Circulation ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 4. Disability ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………
……………………………………………………………………………………… ………………………………………………………………………………………
IV.
Pemeriksaan Status Nyeri Nyeri: □ Ada □ Tidak Penyebab:
SkalaNyeri: Menyebarke:
Kualitas: □ Tajam □ Tumpul □ Kram □ Diremas □ Terbakar □ Tertusuk □ Tertekan □ Kolik □ HilangTimbul □ Menetap
V.
Waktunyeri: □ Pelan □ Tiba-tiba □ Pernahnyerisepertiinisebelumnya □ Lama □ Singkat
Jantung: Nyeri dada sekarang: □ Ya □ Tidak □ Menyebar □ TidakMenyebar Denyutjantung: □ Regular □ Irregular x Frekuensi: /mnt Edema: □ Ya □ Tidak Lokasi:
Lain-lain:
Data Fokus 1. Inspeksi ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………….
2. Palpasi ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 3. Perkusi ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………
……………………………………………………………………………………… ………………………………………………………………………………………
4. Auskultasi ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 5. Tanda-Tanda Vital TekananDarah : ………mmHg Nadi : (Kualitas:……………..;Ritme:………………) Respirasi : (Effort:…………….…..;Ritme:………………) Suhu : ………0C Tingkat Kesadaran : ………………………
………x/mnt ………x/mnt
6. HasilPemeriksaanDiagnostik&Laboratorium a. HasilLaboratorium Tangga l & Jam
Jenis Pemeriksaa n
Hasil Pemeriksaa n
Harga Norma l
Satua n
Interpretas i
b. HasilPemeriksaanDiagnostik …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………
…………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………
VI.
Intervensi, Implementasi, Dan Evaluasi (TABEL) Data
Dx. Kep
Penjelasanilmiah
Tujuan/KriteriaHasil (NOC)
Intervensi (NIC)
Rasional
Implementasi
Evaluasi
(FORMAT RESUMEIGD TRAUMA) RESUME KEPERAWATAN PASIEN TRAUMA RUANG INSTALASI GAWAT DARURAT SEKOLAH TINGGI ILMU KESEHATAN SARI MULIA BANJARMASIN
I.
II.
IdentitasKlien 1. Nama
:
2. JenisKelamin
:
3. Umur
:
4. Pendidikan
:
5. Pekerjaan
:
6. Alamat
:
7. Status Perkawinan
:
8. Agama
:
9. Suku / Bangsa
:
10. TglMasuk RS
:
11. DiagnosaMedis
:
12. No. RekamMedik
:
13. Tanggal Pengkajian
:
RiwayatPasien 1. KeluhanUtama …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. RiwayatPenyakitSekarang …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
3. RiwayatPenyakitDahulu …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. RiwayatPenyakitKeluarga …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
III.
Pengkajian Primer / Triase 1. Airway …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. Breathing …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 3. Circulation …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. Disability …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
IV.
RiwayatKesehatan (SAMPLE) 1. S …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. A …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 3. M …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. P …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 5. L …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 6. E …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
V.
Data Fokus 1. Inspeksi …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. Palpasi …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
…………………………………………………………………………………………….. 3. Perkusi …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. Auskultasi …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 5. Tanda-Tanda Vital TekananDarah Nadi Respirasi Suhu GCS
: ………mmHg : ………x/mnt (Kualitas:……………..;Ritme:………………) : ………x/mnt (Effort:…………….…..;Ritme:………………) : ………0C : ………………………
7. HasilPemeriksaanDiagnostik&Laboratorium …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. ………………………………………………………………………………………….
VI.
Intervensi, Implementasi, Dan Evaluasi (TABEL) Data
Dx. Kep
Penjelasanilmiah
Tujuan/KriteriaHasil (NOC)
Intervensi (NIC)
Rasional
Implementasi
Evaluasi
ASUHAN KEPERAWATAN KRITIS
Nama : …………………………………………………………….. NIM : …………………………………………………………….. TempatPraktek : …………………………………………………………….. Mingguke-/Tanggal : …………………………………………………………….. Nama Usia Alamat No. Register KriteriaKlien Tanggal MRS TanggalPengkajian
: …………………………………………………………….. : …………………………………………………………….. : …………………………………………………………….. : …………………………………………………………….. : …………………………………………………………….... : …………………………………………………………........ : ……………………………………………………………...
I. PENGKAJIAN 1. RiwayatPenyakit a. RiwayatPenyakitSekarang ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………
b. RiwayatPenyakitDahulu ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… c. RiwayatPenyakitKeluarga ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………………………………………………… d. DiagnosaMedis ………………………………………………………………………………………… ………………………………………………………………………………………… …… 2. Secondary Survey a. B1 (Breath) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………
b. B2 (Blood) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………… c. B3 (Brain) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………… d. B4 (Bowel) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………
e. B5 (Bladder) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………… f. B6 (Bone) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………
3. PemeriksaanPenunjang ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………
4. Terapi Farmakologi ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………
Banjarmasin,
2019
(…………………………………….)
II. ANALISA DATA No Data (Symptom) ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... .....
Penyebab (Etiologi)
Masalah (Problem)
.............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. .....
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.....
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No
Data (Symptom)
Penyebab (Etiologi)
Masalah (Problem)
................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ...................................................................
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..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... .....................................................................
..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... .....
..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. .....
..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... .....
III. PRIORITAS DIAGNOSA KEPERAWATAN ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ……………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ……………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………
IV. RENCANA KEPERAWATAN No DiagnosaKeperawatan ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... .....
TujuandanKriteriaHasil ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... .....
Intervensi .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... .....
........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... .....
......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... .....
.......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... .....
No
DiagnosaKeperawatan ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ...........................................................
TujuandanKriteriaHasil ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... .........................................................
Intervensi .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... ..........................................................................
..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... .....
..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... .....
..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... .....
V. IMPLEMENTASI No Tanggal/Jam …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …...
TindakanKeperawatan ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… ……
Paraf
…………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …...
………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… ……
No
Tanggal/Jam …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... ……………………
TindakanKeperawatan ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… …………………………………………………………………………………
Paraf
…... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …...
…… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… ……
VI. EVALUASI No. DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
Evaluasi (SOAP) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
No.
DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ………………………
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... …………………
Evaluasi (SOAP) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. …………………………………………………………………………………
…. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
…... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
…. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
VII. CATATAN OBSERVASI No DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
CatatanObservasi (SOAPIE) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
No
DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ………………………
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... …………………
CatatanObservasi (SOAPIE) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. …………………………………………………………………………………
…. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
…... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
…. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
RESUME KEPERAWATAN PASIEN MEDIK RUANG INSTALASI GAWAT DARURAT SEKOLAH TINGGI ILMU KESEHATAN SARI MULIA BANJARMASIN
I.
II.
IdentitasKlien 1.
Nama
:
2.
JenisKelamin
:
3.
Umur
:
4.
Pendidikan
:
5.
Pekerjaan
:
6.
Alamat
:
7.
Status Perkawinan
:
8.
Agama
:
9.
Suku / Bangsa
:
10. TglMasuk RS
:
11. DiagnosaMedis
:
12. No. RekamMedik
:
13. Tanggal Pengkajian
:
RiwayatPasien 1. KeluhanUtama ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 2. RiwayatPenyakitSekarang ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………….
3. RiwayatPenyakitDahulu ……………………………………………………………………………………… …..…………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………. 4. RiwayatPenyakitKeluarga ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………
III.
Pengkajian Primer / Triase 1. Airway ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 2. Breathing ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………. 3. Circulation ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 4. Disability ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………
……………………………………………………………………………………… ………………………………………………………………………………………
IV.
Pemeriksaan Status Nyeri Nyeri: □ Ada □ Tidak Penyebab:
SkalaNyeri: Menyebarke:
Kualitas: □ Tajam □ Tumpul □ Kram □ Diremas □ Terbakar □ Tertusuk □ Tertekan □ Kolik □ HilangTimbul □ Menetap
V.
Waktunyeri: □ Pelan □ Tiba-tiba □ Pernahnyerisepertiinisebelumnya □ Lama □ Singkat
Jantung: Nyeri dada sekarang: □ Ya □ Tidak □ Menyebar □ TidakMenyebar Denyutjantung: □ Regular □ Irregular x Frekuensi: /mnt Edema: □ Ya □ Tidak Lokasi:
Lain-lain:
Data Fokus 1. Inspeksi ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………….
2. Palpasi ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 3. Perkusi ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………
……………………………………………………………………………………… ………………………………………………………………………………………
4. Auskultasi ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… 5. Tanda-Tanda Vital TekananDarah : ………mmHg Nadi : (Kualitas:……………..;Ritme:………………) Respirasi : (Effort:…………….…..;Ritme:………………) Suhu : ………0C Tingkat Kesadaran : ………………………
………x/mnt ………x/mnt
6. HasilPemeriksaanDiagnostik&Laboratorium a. HasilLaboratorium Tangga l & Jam
Jenis Pemeriksaa n
Hasil Pemeriksaa n
Harga Norma l
Satua n
Interpretas i
b. HasilPemeriksaanDiagnostik …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………
…………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………
VI.
Intervensi, Implementasi, Dan Evaluasi (TABEL) Data
Dx. Kep
Penjelasanilmiah
Tujuan/KriteriaHasil (NOC)
Intervensi (NIC)
Rasional
Implementasi
Evaluasi
(FORMAT RESUMEIGD TRAUMA) RESUME KEPERAWATAN PASIEN TRAUMA RUANG INSTALASI GAWAT DARURAT SEKOLAH TINGGI ILMU KESEHATAN SARI MULIA BANJARMASIN
I.
II.
IdentitasKlien 1. Nama
:
2. JenisKelamin
:
3. Umur
:
4. Pendidikan
:
5. Pekerjaan
:
6. Alamat
:
7. Status Perkawinan
:
8. Agama
:
9. Suku / Bangsa
:
10. TglMasuk RS
:
11. DiagnosaMedis
:
12. No. RekamMedik
:
13. Tanggal Pengkajian
:
RiwayatPasien 1. KeluhanUtama …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. RiwayatPenyakitSekarang …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
3. RiwayatPenyakitDahulu …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. RiwayatPenyakitKeluarga …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
III.
Pengkajian Primer / Triase 1. Airway …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. Breathing …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 3. Circulation …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. Disability …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
IV.
RiwayatKesehatan (SAMPLE) 1. S …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. A …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 3. M …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. P …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 5. L …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 6. E …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
V.
Data Fokus 1. Inspeksi …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 2. Palpasi …………………………………………………………………………………………….. …………………………………………………………………………………………….. ……………………………………………………………………………………………..
…………………………………………………………………………………………….. 3. Perkusi …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 4. Auskultasi …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. …………………………………………………………………………………………….. 5. Tanda-Tanda Vital TekananDarah Nadi Respirasi Suhu GCS
: ………mmHg : ………x/mnt (Kualitas:……………..;Ritme:………………) : ………x/mnt (Effort:…………….…..;Ritme:………………) : ………0C : ………………………
7. HasilPemeriksaanDiagnostik&Laboratorium …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. ………………………………………………………………………………………….
VI.
Intervensi, Implementasi, Dan Evaluasi (TABEL) Data
Dx. Kep
Penjelasanilmiah
Tujuan/KriteriaHasil (NOC)
Intervensi (NIC)
Rasional
Implementasi
Evaluasi
ASUHAN KEPERAWATAN KRITIS
Nama : …………………………………………………………….. NIM : …………………………………………………………….. TempatPraktek : …………………………………………………………….. Mingguke-/Tanggal : …………………………………………………………….. Nama Usia Alamat No. Register KriteriaKlien Tanggal MRS TanggalPengkajian
: …………………………………………………………….. : …………………………………………………………….. : …………………………………………………………….. : …………………………………………………………….. : …………………………………………………………….... : …………………………………………………………........ : ……………………………………………………………...
I. PENGKAJIAN 1. RiwayatPenyakit a. RiwayatPenyakitSekarang ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………
b. RiwayatPenyakitDahulu ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… c. RiwayatPenyakitKeluarga ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………………………………………………… d. DiagnosaMedis ………………………………………………………………………………………… ………………………………………………………………………………………… …… 2. Secondary Survey a. B1 (Breath) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………
b. B2 (Blood) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………… c. B3 (Brain) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………… d. B4 (Bowel) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………
e. B5 (Bladder) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………… f. B6 (Bone) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ……………………
3. PemeriksaanPenunjang ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………
4. Terapi Farmakologi ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………
Banjarmasin,
2019
(…………………………………….)
II. ANALISA DATA No Data (Symptom) ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... .....
Penyebab (Etiologi)
Masalah (Problem)
.............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. .....
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................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ...................................................................
.....
.............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. .....
..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... .....
No
Data (Symptom)
Penyebab (Etiologi)
Masalah (Problem)
................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ...................................................................
.............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... ..............................................
..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... .....................................................................
..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... ..... ................................................................... .....
..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. ..... .............................................. .....
..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... ..... ..................................................................... .....
III. PRIORITAS DIAGNOSA KEPERAWATAN ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ……………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ……………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………
IV. RENCANA KEPERAWATAN No DiagnosaKeperawatan ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... .....
TujuandanKriteriaHasil ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... .....
Intervensi .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... .....
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DiagnosaKeperawatan ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ........................................................... ..... ...........................................................
TujuandanKriteriaHasil ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... ......................................................... ..... .........................................................
Intervensi .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... .......................................................................... ..... ..........................................................................
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V. IMPLEMENTASI No Tanggal/Jam …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …...
TindakanKeperawatan ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… ……
Paraf
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Tanggal/Jam …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... ……………………
TindakanKeperawatan ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… …………………………………………………………………………………
Paraf
…... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …... …………………… …...
…… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… …… ………………………………………………………………………………… ……
VI. EVALUASI No. DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
Evaluasi (SOAP) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
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………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
No.
DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ………………………
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... …………………
Evaluasi (SOAP) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. …………………………………………………………………………………
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VII. CATATAN OBSERVASI No DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… ….
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …...
CatatanObservasi (SOAPIE) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… ….
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DiagnosaKeperawatan ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ……………………… …. ………………………
Tanggal/Jam ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... ………………… …... …………………
CatatanObservasi (SOAPIE) ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. ………………………………………………………………………………… …. …………………………………………………………………………………
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