ASUHAN KEPERAWATAN

DI RUANG ICU RSUP DR KARIADI SEMARANG
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 4.3. PENGKAJIAN PRIMER Airway Breathing Circulation Disability Explosure III. PENGKAJIAN SEKUNDER A. Riwayat penyakit keluarga II. Pemeriksaan fisik .

Dada Inspeksi Palpasi Perkusi Auskultasi 5.1. Abdomen Inspeksi Auskultasi Perkusi TD Nadi RR Suhu . Tanda-tanda vital Tanggal 3. Keadaan Umum 2. Kepala Bentuk mata hidung telinga mulut leher 4.

Genetalia 9. Sistem Integumen Tanggal/jam Warna kulit Turgor 8. 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 Mukosa bibir Capillary refill Kelainan .Palpasi 6.

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

16 40 .3 3.5 80 .54 45 . Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl 13 .65 4 .120 15 .5.12.1.145 3.400 0.4 . Status Cairan Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.107 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L Nilai Nilai .6 .1 98 .5 .11 150 .39 136 .

...............................................45 83 ................... ................................................................8 23.................................................... .................................................. .......................................15 mg/ dL mg/ dL dtk protrombin PPT kontrol Waktu 12................................................................................23 <100 0................... .......................................................................................................................................................................................................4 - dtk tromboplastin pH 36..................................Cholesterol Trigliserid Waktu 50 ................................................................................................................... .2 mmHg mmHg Mmol/L 14................................................ ....................................150 10 ...........................................................8 7........35– pCO2 pO2 HCO3 AADO2 Laktat Base Excess 3............................................4 ..................................................................................................................... Pemeriksaan Penunjang ............................ ................................................................................................................................ .............................................................103 18 ................................. ................... .......................45 35 ............... ......................................................200 30 ....................................................................... .................................................................................................. ................................................................................................................................................. ............................................................................. ..................................... ...

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

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

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

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

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

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

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

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