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

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

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. 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.

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

65 4 . Pemeriksaan Penunjang 1) Laboratorium Pemeriksaan Nilai Satuan Nilai Hb Ht Eritrosit Leukosit Trombosit Creatinin Albumin Gula Sewaktu Ureum Na K Cl 13 .120 15 .11 150 .5 80 .54 45 .1 98 .39 136 .16 40 . Status Cairan Tanggal Intake Parenteral : Output Balance Cairan Urine : IWL : Feses : Muntah : Drainase : Total : Minum : Makan : Total : 13.145 3.6 .400 0.5.3 3.1.5 .107 % % jt/ mmk ribu/ mmk ribu/mmk mg/ dL mg/ dL mg/ dL mg/ dL mmol/ L mmol/ L mmol/ L Nilai Nilai .4 .12.

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

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

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

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

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

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

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

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

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