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BLANKO PENGKAJIAN ASUHAN KEPERAWATAN KEGAWAT DARURATAN DI RUANG IGDTRANSCRIPT
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