LAPORAN KASUS KELOLAAN

ASUHAN KEPERAWATAN PADA KEGAWATDARURATAN

SISTEM.......................................PADA......................
DENGAN...................................................
DI RUANG ICU RSUD TUGUREJO SEMARANG
A. Pengkajian
1. Identitas
Identitas klien
Nama klien

Umur

Jenis kelamin

Alamat

Tanggal masuk

Tanggal pengakajian

Jam

Diagnosa medis

2. Keluhan utama :

3. Pengkajian Fokus
a. Pengkajian Primer
1) Airway

2) Breathing

3) Circulasi

4) Disability

5) Eksposure

b. Pengkajian Sekunder
1) Riwayat Penyakit Sekarang

2) Riwayat Penyakit Dahulu

3) Riwayat Penyakit Keluarga

4. Pemeriksaan Fisik

1) Kepala dan muka

Inspeksi:
.........................................................................................................................................
...........................................................................................................
Palpasi :
.........................................................................................................................................
...........................................................................................................
2) Mata dan telinga
Inspeksi :
.........................................................................................................................................
...........................................................................................................
Palpasi

.........................................................................................................................................
...........................................................................................................
3) Hidung
Inspeksi :
..........................................................................................................................
Palpasi :
..........................................................................................................................
4) Mulut dan tenggorokan
Inspeksi

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

Palpasi

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

5) Kulit
Inspeksi:
.........................................................................................................................................
...........................................................................................................
Palpasi : ...........................................................................................................
6) Dada/Jantung/paru
Inspeksi dada :
.........................................................................................................................................
...........................................................................................................
Palpasi paru :
.........................................................................................................................................
...........................................................................................................
Auskultasi paru : ..............................................................................................
Perkusi paru : ...................................................................................................
Auskltasi jantung :
.........................................................................................................................................
...........................................................................................................
Palpasi jantung : ..............................................................................................
Perkusi jantung : ..............................................................................................
7) Abdomen
Inspeksi :
.........................................................................................................................................
...........................................................................................................
Askultasi : ........................................................................................................
Palpasi :
.........................................................................................................................................
...........................................................................................................

Perkusi : ...........................................................................................................

8) Genetalia
.........................................................................................................................................
.........................................................................................................................................
...........................................................................................
9) Ekstremitas
Inspeksi :
.........................................................................................................................................
...........................................................................................................
Palpasi : ............................................................................................................

10) Parameter umum

Kesadaran

:..................

Kesadaran

:..................

Vital sign
Tekannan Darah

: ............... mmHg

Map

:................

Rr

: .........x/menit

Hr

: .........x/menit

SPO2

: ............

Suhu

: .........oC

5. Prosedur diagnostik dan laboratorium

Prosedur
Tgl
diagnostik dan pemeriksaan
laboratorium

Indikasi dan tujuan

Hasil

Nilai normal

Analisa

Tanggung Jawab Perawat :

Sebelum :

Sesudah :

Setelah :

B. Analisa data
DATA

MASALAH

ETIOLOGI

10

1. Diangnosa Keperawatan
1. ...................................................................................................................................................................................
2. ...................................................................................................................................................................................
3. ...................................................................................................................................................................................
4. ...................................................................................................................................................................................
5. ...................................................................................................................................................................................

11

C. Nursing Care Plan

No

Hari/

Tujuan dan Kreteria Hasil

Intervensi Keperawatan

Rasional

Paraf

Tanggal

12

13

14

D. IMPLEMENTASI
1. Medical Management
IVF, O2 terapi
Medical

Tanggal

Penjelasan secara umum

Indikasi dan tujuan

Respon

management Terapi

15

2. Obat obatan

Nama

Tanggal

Cara,

obat

Terapi

frekuensi

dosis,

Cara kerja obat, fungsi

Respon

dan klasifikasi

16

17

3. Diet
Jenis

Tanggal Penjelasan umum

diit

Terapi

Indikasi dan

Makanan

Tujuan

Spesifik

Respon

18

4. Aktifitas dan Latihan

Jenis

Tanggal

aktivitas

Terapi

Penjelasan umum

Indikasi dan Tujuan

Respon
Klien

dan latihan

19

D. IMPLEMENTASI KEPERAWATAN
Tanggal/Hari No. Dx

Tindakan Keperawatan

Respon Klien

Paraf

jam

20

21

22

23

24

25

E. EVALUASI
Hari/Tanggal No. Dx

Evaluasi Respon Klien

Paraf

26

27

F. KESIMPULAN

28