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

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

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

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.Palpasi 6. Sistem Persyarafam a) Fungsi serebral/Status Mental Tanggal Status mental • Tingkat kesadaran • GCS • Gaya bicara Fungsi Intelektual Mukosa bibir Capillary refill Kelainan .

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

11 150 .400 0.12.39 136 .120 15 .1 98 .54 45 .5 80 .3 3.16 40 .4 .65 4 .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 : 13.1.5.6 . Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl 13 .145 3.5 .

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

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

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

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

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

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

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

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