ASUHAN KEPERAWATAN

DI RUANG ICU RS DR MOEWARDI SURAKARTA
I.

PENGKAJIAN
Tanggal masuk

:

Tanggal pengkajian

:

A. Identitas Pasien
Nama

:

Umur

:

Alamat

:

No Register

:

Ruang

:

Cara Pengkajian

: Anamnesa, pemeriksaan fisik, catatan rekam medis

Diagnosa Medis

:

Penanggung jawab :
B. Riwayat Kesehatan
1. Keluhan utama

2. Riwayat penyakit sekarang

PENGKAJIAN PRIMER Airway Breathing Circulation Disability Explosure III.3. Pemeriksaan fisik . Riwayat penyakit dahulu 4. PENGKAJIAN SEKUNDER A. Riwayat penyakit keluarga II.

Keadaan Umum 2.1. Tanda-tanda vital Tanggal 3. Abdomen Inspeksi Auskultasi Perkusi TD Nadi RR Suhu . Kepala Bentuk mata hidung telinga mulut leher 4. Dada Inspeksi Palpasi Perkusi Auskultasi 5.

Sistem Integumen Tanggal/jam Warna kulit Turgor 8. Genetalia 9.Palpasi 6. Sistem Persyarafam a) Fungsi serebral/Status Mental Tanggal Status mental • Tingkat kesadaran • GCS • Gaya bicara Fungsi Intelektual • Orientasi waktu Mukosa bibir Capillary refill Kelainan . Ekstremitas Ekstremitas Atas Kanan Tanggal/ jam Kesemutan Edema Kiri Nyeri Kesemutan Edema Nyeri Gerak Kekuatan Otot : Ekstremitas Bawah Kanan Tanggal/ jam Kesemutan Edema Kiri Nyeri Kesemutan Edema Nyeri Gerak Kekuatan Otot : 7.

Eliminasi 11. alamiah.• Orientasi tempat • Orientasi orang Daya pikir • Spontan. masuk akal • Kesulitan berpikir • Halusinasi Status emosional • Alamiah dan datar • Pemarah • Cemas • Apatis 10. Status Cairan . Tingkat ketergantungan Bathing Dressing Toileting Transfering Continence Feeding Indeks KATZ 12.

4 .Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.3 3.107 50 .54 45 .16 40 .400 0.1.145 3.39 136 .5 .5 80 .65 4 .1 98 .120 15 .200 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L mg/ dL Nilai Nilai .6 .5. Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl Cholesterol 13 .11 150 .

.... ............... ............................................... ............................................................................45 83 ........................................................................................................................................................................................8 23.................................... .................................................................4 - dtk tromboplastin pH 36........................8 7... ............................15 mg/ dL dtk protrombin PPT kontrol Waktu 12...................................... ................ .....................Trigliserid Waktu 30 ...................150 10 ........................ ............................. ......................................................................................................................................................................................................................................................................................................... ................................................................ ....................................................................................................................................................23 <100 0.... Pemeriksaan Penunjang .............................................................................................................................................................103 18 ........ .....35– pCO2 pO2 HCO3 AADO2 Laktat Base Excess 3.....................................................................2 mmHg mmHg Mmol/L 14............................................................................................................................ .............................................................................. .......................45 35 ..................................................................................................................... ...................................................................4 ......................... .......

.......................................................................................................................................................... .................... ............................................................................... ........................................................................... ............................................................................................... ................................................................................................................................................. ...... ........................................................................................................................................................... .................................................................................................................................................. .......................................................................................................................................... ................................................................................................... ...................................................................................................................................................................................... ..... ........ ................................................................................................................................................................... .............................................................................................................................................................................Therapy ......................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................ ............................... ............................................................................................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................... ........................ ............................................................... ................................................................................................................................................... ......... ........................................................................................ .. ............................................................................................................................................................................................................................................................................. 13..........................

................................................................................................................................ .................................................................... .................................................................................................................................................... .................... .................................................................................................................................................................................................... ........................................... ............................................................................ ........................................ .................................................... ..................................................................................................................................................................................................................................................................................................................................... .........................................................................

ANALISA DATA Nama : No CM : Usia Dianosa Medis : : TANGGAL DATA FOKUS ETIOLOGI MASALAH TTD .

...... …………………………………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………………………………………... 6................ .................. 4 ………………………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………………………………………... 5.................. ………………………………………………………………………………………………………………………………………...... …………………………………………………………………………………………………………………………………………………... 3... ………………………………………………………………………………………………………………………………………............ …………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………................ ……………………………………………………………………………………………………………………………………….......... 2...PRIORITAS DIAGNOSA KEPERAWATAN 1..... …………………………………………………………………………………………………………………………………………………..... ………………………………………………………………………………………………………………………………………....

KEPERAWATAN TUJUAN DAN KRITERIA HASIL INTERVENSI TTD .RENCANA ASUHAN KEPERAWATAN Nama : No CM : Usia Diagnosa Medis : No : DIAGNOSA Dx.

IMPLEMENTASI RESPON TTD . DX.IMPLEMENTASI KEPERAWATAN TGL/JAM NO.

EVALUASI Nama : No CM : Usia Diagnosa Medis : : TGL/JAM NO DX EVALUASI ( SOAP ) TTD .

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