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

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

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

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 . Genetalia 9.Palpasi 6.

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

Status Cairan Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.4 . Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl 13 .5 .145 3.11 150 .5.16 40 .120 15 .65 4 .6 .107 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L Nilai Nilai .1 98 .400 0.5 80 .39 136 .54 45 .12.1.3 3.

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

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

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

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

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

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

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

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