ASUHAN KEPERAWATAN PADA Ny.

D
DENGAN DIAGNOSA CHF
DIRUANG ICU
RSI ISLAM SULLTAN AGUNG SEMARANG

Oleh :
Deny Prasetyo
092111129

PROGRAM STUDI S1 KEPERAWATAN

FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2015

I.

Pengkajian Keperawatan (tanggal, waktu, tempat)

Tanggal Masuk

: 26 Novmber 2015

Tanggal Pengkajian

: 21 Desember 2015

A. Identitas Pasien
-

Nama

: Ny. D

Umur

: 60 Thn

Alamat

: Jl. Genuksari Genuk Semarang

No. Register

Ruang

: ICU

Cara Pengkajian

: wawancara, observasi, pemeriksaan fisik,

: 01248736

status RM
-

Diagnosa Medis

: CHF

Penanggung jawab Klien

-

Nama

: Ny. K

Pekerjaan

: swasta

Alamat

: Jl. Genuksari Genuk Semarang

Hubugan dengan klien

: anak

B. Riwayat Kesehatan dan diet

1. Keluhan Utama
Sesak napas
2. Riwayat Penyakit Sekarang
Pasien mengatakan sesak napas 2 minggu ini, mulai tidak dapat bicara
2 minggu, lemas
3. Riwayat Penyakit Dahulu
Pasien mengatakan punya riwayat penyakit jantung
4. Riwayat Penyakit Keluarga
Pasien mengatakan kalau dari keluarga pasien tidak ada yang menderita
sakit seperti saat ini.

II. PENGKAJIAN PRIMER

2

Airway

Jalan nafas stabil dibantu dengan ET dan oksigen

Breathing

Circulation

Disability

Explosure

III. PENGKAJIAN SEKUNDER

A. Pemeriksaan fisik
1. Keadaan Umum : Komposmentis, GCS 15
2. Tanda-tanda vital
Tanggal/Jam
TD (mmHg)
HR : Frekuensi
RR : Fekuensi
Suhu (oC)

22 - 12 -2015 / 06.00
122/75 mmHg
111x/menit
30x per menit
36,6oC

3. Kepala dan Leher

Yang dikaji

Keterangan
3

Bentuk
Rambut
Mata

Mesochepal
Pendek, bersih, warna hitam sedikit beruban
Simetris, pupil isokor, conjungtiva tidak anemis, tidak
menggunakan alat bantu penglihatan.
Simetris, bersih tidak ada sekret, tidak menggunakan alat
bantu pendengaran.
Simetris, terpasang NGT
Simetris, bibir kering, nafas bau, tidak ada pembengkakan
pada lidah
Gerakan leher normal, tidak ada pembesaran kelenjar tiroid,
reflek menelan baik.

Telinga
Hidung
Mulut
Leher

4. Dada
Yang Dikaji
Inspeksi

Keterangan
Bentuk dada simetris, warna sawo matang,perkembangan
dada sama, ekspansi dada simetris
Taktil fremitus teraba,
Pekak
Suara wheezing

Palpasi
Perkusi
Auskultasi
5. Abdomen
Yang Dikaji
Inspeksi
Auskultasi
Palpasi
Perkusi

Keterangan
Bentuk simetris, gerakan normal, lidak ada lesi
Peristaltik usus terdengar,
Tidak ada pembesaran hati, ginjal
Suara timpani,tidak ada cairan/ massa.

6. Ekstremitas
Ekstremitas Atas
Tanggal/ja
m
7/12/2015
10.00 WIB
Gerak

Kanan
kesemuta
n
-

Edem
a
-

Kekuatan otot :

Eksremitas Bawah
4

Baa
l
-

Nyer
i
-

Kiri
kesemuta
n
-

Edem
a
-

Baa
l
-

Nyer
i
-

Tanggal/ja
m
7/12/2015
10.00 WIB
Gerak

Kanan
kesemuta
n
-

Edem
a
-

Baa
l
-

Nyer
i
-

Kiri
kesemuta
n
-

Edem
a
-

Baa
l
-

Nyer
i
-

Kekuatan otot :
7. Sistem Integumen
Tanggal/ja
m
21-12-2015

Warna
kulit
Sawo
matang

Turgor
Jelek

8. Genetalia
Terpasang DC kateter
9. Sistem Persyarafam
a) Fungsi serebral/Status Mental
Tanggal
Status mental
Tingkat kesadaran
GCS
Gaya bicara
Fungsi Intelektual
Orientasi waktu
Orientasi tempat
Orientasi orang
Daya pikir
Spontan, alamiah, masuk
akal
Kesulitan berpikir
Halusinasi
Status emosional
Alamiah dan datar
Pemarah
Cemas
Apatis

Mukosa
bibir
Kering

Capillary
refill
4 detik

Kelainan
Tidak ada

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

13 16
40 - 54

%
%
6

Nilai

Nilai

Eritrosit
Leukosit
Trombosit

45 65
4 11
150

jt/ mmk
ribu/ mmk
ribu/mmk

Creatinin
Albumin
Gula Sewaktu
Ureum
Na

400
0.6 - 1.3
3.4 5
80 120
15 39
136

mg/ dL
mg/ dL
mg/ dL
mg/ dL
mmol/ L

K
Cl
Cholesterol
Trigliserid
Waktu

145
3.5 - 5.1
98 107
50 200
30 150
10 15

mmol/ L
mmol/ L
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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15. Therapy
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ANALISA DATA
Nama :

No

CM :
Usia

:
Dianosa Medis :

TANGGAL

DATA FOKUS
9

ETIOLOGI

PRIORITAS DIAGNOSA KEPERAWATAN

1.

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2.

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10


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3.

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4

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5.

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11

RENCANA ASUHAN KEPERAWATAN

Nama :

No

CM :
Usia

:
Diagnosa Medis :

No

DIAGNOSA

TUJUAN DAN KRITERIA

Dx

KEPERAWATAN

HASIL

12

INTERVENS

IMPLEMENTASI KEPERAWATAN
TGL/JAM

NO.

IMPLEMENTASI

DX.

EVALUASI
Nama :

No

CM :
Usia

:
Diagnosa Medis :
13

TGL/JAM

NO

EVALUASI ( SOAP )

DX

14