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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 dahulu

4. Riwayat penyakit keluarga

II.

PENGKAJIAN PRIMER

Airway

Breathing

Circulation

Disability

Explosure

III.

PENGKAJIAN SEKUNDER
A. Pemeriksaan fisik

1. Keadaan Umum
2. Tanda-tanda vital
Tanggal

3. Kepala
Bentuk
mata
hidung
telinga
mulut
leher

4. Dada
Inspeksi
Palpasi
Perkusi
Auskultasi
5. Abdomen
Inspeksi
Auskultasi
Perkusi

TD

Nadi

RR

Suhu

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 Integumen
Tanggal/jam

Warna kulit

Turgor

8. Genetalia

9. Sistem Persyarafam
a) Fungsi serebral/Status Mental
Tanggal
Status mental
Tingkat kesadaran
GCS
Gaya bicara
Fungsi Intelektual

Mukosa
bibir

Capillary
refill

Kelainan

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. Tingkat ketergantungan


Bathing
Dressing
Toileting
Transfering
Continence
Feeding
Indeks KATZ

12. Status Cairan


Tanggal

Intake
Parenteral :

Output

Balance Cairan

Urine :
IWL :
Feses :
Muntah :
Drainase :
Total :

Minum :
Makan :
Total :

13. Pemeriksaan Penunjang


1) Laboratorium
Pemeriksaan
Nilai

Satuan
Nilai

Hb
Ht
Eritrosit
Leukosit
Trombosit
Creatinin
Albumin
Gula Sewaktu
Ureum
Na
K
Cl

13 - 16
40 - 54
45 - 65
4 - 11
150 - 400
0.6 - 1.3
3.4 - 5
80 - 120
15 - 39
136 - 145
3.5 - 5.1
98 - 107

%
%
jt/ mmk
ribu/ mmk
ribu/mmk
mg/ dL
mg/ dL
mg/ dL
mg/ dL
mmol/ L
mmol/ L
mmol/ L

Nilai

Nilai

Cholesterol
Trigliserid
Waktu

50 - 200
30 - 150
10 - 15

mg/ dL
mg/ dL
dtk

protrombin
PPT kontrol
Waktu

12.8
23.4 -

dtk

tromboplastin
pH

36.8
7,35

pCO2
pO2
HCO3
AADO2
Laktat
Base Excess

3,45
35 - 45
83 - 103
18 - 23
<100
0,4 - 2

mmHg
mmHg
Mmol/L

14. Pemeriksaan Penunjang

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13.Therapy
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ANALISA DATA
Nama :

No CM :

Usia

Dianosa Medis :

TANGGAL

DATA FOKUS

ETIOLOGI

MASALAH

TTD

PRIORITAS DIAGNOSA KEPERAWATAN


1. ...................
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2. ...................
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RENCANA ASUHAN KEPERAWATAN


Nama :

No CM :

Usia

Diagnosa Medis :

No

:
DIAGNOSA

Dx. KEPERAWATAN

TUJUAN DAN KRITERIA


HASIL

INTERVENSI

TTD

IMPLEMENTASI KEPERAWATAN
TGL/JAM

NO.
DX.

IMPLEMENTASI

RESPON

TTD

EVALUASI
Nama :

No CM :

Usia

Diagnosa Medis :

TGL/JAM

NO
DX

EVALUASI ( SOAP )

TTD