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 SEKUNDER A. PENGKAJIAN PRIMER Airway Breathing Circulation Disability Explosure III. Riwayat penyakit keluarga II. Riwayat penyakit dahulu 4.3. Pemeriksaan fisik .

Dada Inspeksi Palpasi Perkusi Auskultasi 5. Keadaan Umum 2. Abdomen Inspeksi Auskultasi Perkusi TD Nadi RR Suhu . Tanda-tanda vital Tanggal 3. Kepala Bentuk mata hidung telinga mulut leher 4.1.

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

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. alamiah. Status Cairan .• Orientasi tempat • Orientasi orang Daya pikir • Spontan. Eliminasi 11.

6 .54 45 .400 0. Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl Cholesterol 13 .16 40 .11 150 .5 .4 .3 3.200 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L mg/ dL Nilai Nilai .107 50 .1.5.1 98 .145 3.120 15 .5 80 .Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.39 136 .65 4 .

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

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

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

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

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

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

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

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