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

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

Tanda-tanda vital Tanggal 3. Abdomen Inspeksi Auskultasi Perkusi TD Nadi RR Suhu .1. Kepala Bentuk mata hidung telinga mulut leher 4. Keadaan Umum 2. Dada Inspeksi Palpasi Perkusi Auskultasi 5.

Palpasi 6. 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. Sistem Persyarafam a) Fungsi serebral/Status Mental Tanggal Status mental • Tingkat kesadaran • GCS • Gaya bicara Fungsi Intelektual • Orientasi waktu Mukosa bibir Capillary refill Kelainan . Genetalia 9. Sistem Integumen Tanggal/jam Warna kulit Turgor 8.

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

Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl Cholesterol 13 .400 0.65 4 .145 3.5 80 .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 .3 3.1 98 .1.54 45 .4 .11 150 .16 40 .Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.5.5 .120 15 .6 .107 50 .39 136 .

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

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

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

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

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

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

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

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

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