YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

JLN. BELIANG NO 110 TELP. (0536) 3227707

FORMAT PENGKAJIAN ICU

Nama Mahasiswa :
NIM :
Tanggal Pengkajian :

A. DATA KLIEN
Inisial Klien : No RM :
Usia :
Alamat :
Status : Menikah/ Tidak menikah/Janda/Duda
Pekerjaan :
Pendidikan :
Agama :
Tgl MRS :

Cara Pasien Masuk Peralatan Saat Masuk:

Kursi Roda Brankard NTT/OTT/TT No .......
Tipe Masuk Airway No .......
Elektif Emergensi Oksigenasi: Ambubag ....ltr/mnt
Asal Ventilator .....ltr/mnt
Bangsal IGD NRM/RM ......ltr/mnt
Pengantar: Nasal/Kanula
Keluarga Lainnya: ................ .....ltr/mnt
IV line: lokasi;...........
CVP : lokasi; ..........
NGT : lokasi: ............
D/C urine No : .............
Drain No ; .............
WSD lokasi: .............

Obat/Barang yang dibawa: Sosial:

Obat: Pola Tidur:
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............................................. Kebiasan merokok: ya tidak
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Lab/X-Ray: Alkohol: ya tidak

Kacamata; ya Tidak
Gigi Palsu: ya Tidak
 Keluhan utama/ alasan masuk ICU :
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Keadaan umum: (uraikan kondisi klien, alat medis yang digunakan)
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B. RIWAYAT KESEHATAN
1. Riwayat Penyakit Sekarang :
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2. Riwayat Penyakit Dahulu :
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3. Riwayat Penyakit Keluarga :
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C. TANDA-TANDA VITAL:
Suhu : .......................... . Axila Rectal Oral
TD : .......................... MAP : .................................
Nadi : ..........................
RR : .......................... reguler ireguler
D. PEMERIKSAAN FISIK
1. Pernapasan :
Ventilasi : Spontan
Bagging
Ventilator
Bunyi Nafas : Normal Tidak Normal
Masalah lain :
 2. Kardiovaskular :
Redial
Apikal
Edema 0 1 2 3 4 5
BJ Normal Abnormal
Gambaran EKG :

Masalah lain :

3. Neurologi
Kesadaran :
GCS : E: M: V:
Pupil : Ukuran R/L: ....../........ Reaksi R/L : ......./.......
Pergerakan : Kaki R/L: ....../....... Tangan R/L : ....../........
Kekuatan : (0) (1) (2) (3) (4) (5)
Nyeri :
Masalah lain :

4. Gastrointestinal
Abdomen : Lembut Tegang Distensi Keras
Bising usus : Ada Tidak ada Jumlah: .........
Masalah lain :

5. Kulit
Warna : kemerahan
Turgor : Lembab Dehidrasi Edema
Lesi : Ya Tidak
Dekubitus : Ya Tidak Grade : ..............
Masalah lain:

6. Eliminasi Urine/Alvi
Kandung Kemih : Teraba Tidak teraba
Warna Urine : Jernih Keruh Sedimentasi
Inkotinensia : Ya Tidak
Masalah lain :

E. MASALAH KEPERAWATAN:
o Bersihan jalan napas, tak efektif
o Hipotermia
o Hipertermia
o Resiko terhadap infeksi
o Kekurangan volume cairan
o Kelebihan volume cairan
o Kerusakan verbal, komunikasi
o Kurang perawatan diri (makan,minum,hygiene, berpakaian, toilleting)
o Kerusakan mobilitas fisik
o Nyeri akut/ nyeri kronik
o Resiko terhadap pengehntian pernapasan
o Penurunan curah jantung
o Perubahan perfusi
o Kerusakan pertukaran gas
o Tidak efektif pola napas
o Disfungsi respon penyapihan ventilator
o Resiko terhadap perubahan suhu tubuh
o Tak efektif termoregulasi
o Ketidakmampuan untuk melanjutkan ventilasi spontan
o ......................................................................
o ......................................................................
o ........................................................................

Palangka Raya, ..............................................

Perawat Pelaksana,

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 ANALISA DATA
Data Etiologi Masalah
 INTERVENSI/IMPLEMENTASI
Tanggal/Jam Diagnosa Keperawatan Intervensi Implementasi Evaluasi