Kamis, 24 April 2014

Format ASKEP GADAR STIKes KESOSI



FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT
SARJANA KEPERAWATAN STIKes KESOSI

Nama Mahasiswa
:
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Tanggal
:
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NIM
:
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Tempat
:
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Inisial Klien
:
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Dx Medik
:
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I.     Pengkajian Primer
A.    Data Fokus
Airway             : ............................................................................................................................
Breathing          : ............................................................................................................................
Circulation        : ............................................................................................................................
Disability          : ............................................................................................................................
Exposure          : ............................................................................................................................
B.     Diagnosa Keperawatan Utama
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C.     Rasional Diagnosa Keperawatan Utama
.......................................................................................................................................................
.......................................................................................................................................................
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D.    Tindakan Keperawatan yang Dilakukan dan Rasionalnya
Tindakan Utama
Rasional
1.      Treatment
a.       ............................................................
b.      ............................................................
c.       ............................................................
2.      Diagnostik
a.       ............................................................
b.      ............................................................
c.       ............................................................

a.       ............................................................
b.      ............................................................
c.       ............................................................

a.       ............................................................
b.      ............................................................
c.       ............................................................

E.     Prinsip Tindakan
.......................................................................................................................................................
.......................................................................................................................................................
F.      Evaluasi
S : .................................................................................................................................................
O : .................................................................................................................................................
A : .................................................................................................................................................
P : .................................................................................................................................................
G.    Bahaya yang Mungkin Timbul (Komplikasi) Akibat Tindakan Tersebut (Jika Ada):
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H.    Tindakan Keperawatan Lain yang Dapat Dilakukan Untuk Mengatasi Masalah Tersebut
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I.       Evaluasi Diri
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II.  Pengkajian Sekunder
A.    Keluhan Utama
.......................................................................................................................................................
.......................................................................................................................................................
B.     Riwayan Kesehatan
Sign & Symptom          : ................................................................................................................
Alergi                           : ................................................................................................................
Medikasi                       : ................................................................................................................
Provokasi                      : ................................................................................................................
Environment                 : ................................................................................................................
Last Meal                     : ................................................................................................................
C.     Riwayat Trauma
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D.    Pemeriksaan Fisik
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E.     Labor & Diagnostik
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F.      Diagnosa Keperawatan Prioritas
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G.    Tindakan Keperawatan
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H.    Rencana Tindak Lanjut/Follow Up/Pulang, dll
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