PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

(INSTALASI RAWAT INTENSIF)

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

I. Identitas Klien

Nama : No. RM :
Tanggal Lahir : Tanggal masuk RS :
Jenis Kelamin : Tanggal masuk IRI :
Agama : Asal ruang/ RS :
Pendidikan : Tanggal Pengkajian :
Pekerjaan : Sumber Informasi :
Alamat :
Status :
Perkawinan

II. Riwayat Kesehatan

1. Diagnosa medik
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2. Keluhan utama dan alasan masuk instalasi rawat intensif ……………..

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4. Riwayat penyakit sekarang

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5. Riwayat kesehatan terdahulu:

a. Penyakit yang pernah dialami
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b. Alergi (obat, makanan, dll)
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c. Imunisasi
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d. Kebiasaan
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e. Obat-obat yang digunakan
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6. Riwayat penyakit keluarga
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Genogram:

III. Pengkajian Keperawatan

1. Tanda vital & nyeri

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2. Pernafasan
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3. Kardiovaskuler
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4. Neurologi dan sensori

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5. Gastrointestinal
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6. Muskuloskeletal & integumen

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7. Genito urinari
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8. Risiko keamanan
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9. Aktivitas, istirahat & mobilisasi

Aktivitas harian (Activity Daily Living)

Kemampuan perawatan diri 0 1 2 3 4
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM

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10. Spiritual
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13. Keadaan lokal .

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V. Terapi
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VI. Pemeriksaan Penunjang & Laboratorium

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Pengambil Data

(__________________)

ANALISA DATA

NO DATA PENUNJANG MASALAH ETIOLOGI

 RENCANA KEPERAWATAN

NO DIAGNOSA TUJUAN DAN INTERVENSI RASIONAL

KEPERAWATAN KRITERIA HASIL
 CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASI