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

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

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

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

120 15 .1 98 .5.16 40 .5 .11 150 .3 3.400 0.39 136 .145 3.6 .54 45 .65 4 .12. Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl 13 .5 80 .107 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L Nilai Nilai . Status Cairan Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.4 .1.

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

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

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

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

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

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

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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