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

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

Palpasi 6. Genetalia 9. 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. Sistem Persyarafam a) Fungsi serebral/Status Mental Tanggal Status mental • Tingkat kesadaran • GCS • Gaya bicara Fungsi Intelektual Mukosa bibir Capillary refill Kelainan .

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

16 40 .6 .5.65 4 .4 .145 3.5 80 .54 45 .400 0.107 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L Nilai Nilai .5 .1 98 .120 15 . Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl 13 .3 3.1.39 136 .11 150 .12. Status Cairan Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.

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

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

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

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

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

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

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

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

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