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

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

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

Genetalia 9. 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.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 . Sistem Integumen Tanggal/jam Warna kulit Turgor 8.

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

39 136 .5.1.4 .3 3. Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl Cholesterol 13 .5 80 .145 3.1 98 .6 .5 .Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.200 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L mg/ dL Nilai Nilai .54 45 .65 4 .107 50 .16 40 .400 0.11 150 .120 15 .

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

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

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

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

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

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

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

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

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