FORMAT ASUHAN KEPERAWATAN STASE KRITIS DAN GAWAT DARURAT PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS LAMBUNG MANGKURAT Nama/NIM : Herry Setiawan,S.Kep. / I1B108227 Kelompok : C Ners Muda UNLAM Ruangan : Instalasi Gawat Darurat (IGD) RSUD Ulin Banjarmasin Tanggal Praktik : …………………………… Tanggal Pengkajian : …………….…. Identitas Pasien Nama : ……………………. Suku : ……………………. Umur : ……………………. Agama : ……………………. Jenis Kelamin : Laki / Perempuan Tgl.MRS : ……………………. Pendidikan : ……………………. No.RMK : ……………………. Alamat : ……………………. ……………………. Dx.Medis : ……………………. ……………………. Pengkajian Primer Keluhan Utama …………………………………………………………………………………………………... …………………………………………………………………………………………………... Riwayat Penyakit Sekarang …………………………………………………………………………………………………... …………………………………………………………………………………………………... …………………………………………………………………………………………………... …………………………………………………………………………………………………... Riwayat Penyakit Dahulu …………………………………………………………………………………………………... …………………………………………………………………………………………………... …………………………………………………………………………………………………... PQRST (apabila ada nyeri) …………………………………………………………………………………………………... …………………………………………………………………………………………………... …………………………………………………………………………………………………...
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
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)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data
NIM : I1B108239Kelompok : 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)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Pengkajian Sekunder
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C
Pengkajian Head to ToeKeadaan Umum ……………………………………………………………………
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data
NIM : I1B108203Kelompok : 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)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Pengkajian Sekunder
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C
Pengkajian Head to ToeKeadaan Umum ……………………………………………………………………
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data
NIM : I1B108234Kelompok : 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)…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Pengkajian Sekunder
FORMAT ASUHAN KEPERAWATAN
STASE KRITIS DAN GAWAT DARURAT
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS LAMBUNG MANGKURAT
Tanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C
Pengkajian Head to ToeKeadaan Umum ……………………………………………………………………
Data Penunjang…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...
Terapi…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...Analisis Data