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ASUHAN KEPERAWATAN

PADA .. DENGAN DIAGNOSA MEDIS


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DI INTENSIVE CARE UNIT (ICU) RSUP DR KARIADI
Disusun untuk Memenuhi Tugas pada Praktik Klinik Stase GawatDarurat
Pembimbing Klinik :...
Pembimbing Akademik :...
Pembimbing Akademik :...

Oleh:
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PROGRAM PROFESI NERS XXX

DEPARTEMEN ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN

UNIVERSITAS DIPONEGORO

SEMARANG
2017
ASUHAN KEPERAWATAN

Tanggal pengkajian : ............................................. Jam : ............................


Tanggal masuk : ............................................. Jam : ............................
Ruang : ....................................................................................

A. Identitas
1. Klien/Pasien
a. Nama (Inisial) : ....................................................................
b. No. Rekam medik : ....................................................................
c. Umur : ....................................................................
d. Jenis kelamin :.....................................................................
e. Agama :.....................................................................
f. Pendidikan :.....................................................................
g. Pekerjaan : .....................................................................
h. Suku :.....................................................................
i. Bahasa :.....................................................................
j. Alamat :.....................................................................
k. Diagnosa Medis : .....................................................................

2. Identitas Penanggung Jawab


a. Nama (Inisial) : .....
b. Umur : .
c. Jenis kelamin : .
d. Alamat : ..
e. Hubungan dengan klien : ..

B. Pengkajian Primer
1. Airway
Look :
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Listen:
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Feel:
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2. Breathing
Look:
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Listen:
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Feel:
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3. Circulation :
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4. Disability:
....
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5. Exposure:
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C. Pengkajian Sekunder
1. Anamnesis (SAMPLE)
S (Signs and Symptoms)
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A (Allergies)
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M (Medications)
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P (Pertinent Medical History)
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L (Last Meal)
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E (Events)
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2. Pemeriksaan Fisik:
Keadaan Umum :
....
....
Kesadaran :
....
....
Vital sign:
TD : ..
HR : ..
RR : ..
Suhu : ..

a. Kepala
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b. Telinga
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c. Mata
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d. Mulut dan Gigi
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e. Hidung
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f. Leher
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g. Dada dan paru
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h. Jantung
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i. Abdomen
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j. Genetalia
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k. Ekstremitas
Ekstremitas Atas




Ekstremitas Bawah




3. Pengkajian Fungsional
a. Oksigenasi
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b. Nutrisi dan Cairan
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c. Eliminasi
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d. Termoregulasi
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e. Aktifitas Latihan/Mobilisasi
Keterangan 0 1 2 3 4
Mandi
Berpakaian
Eliminasi
Makan dan Minum
Mobilisasi
Ambulasi

Keterangan : 0 : mandiri
1 : Dibantu sebagian
2 : Perlu bantuan orang lain
3 : Perlu bantuan orang lain dan alat
Keterangan :
4 : Tergantung penuh
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f. Seksualitas
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g. Psikososial (Stress, Koping, dan Konsep Diri)
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h. Rasa Aman dan Nyaman
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i. Spiritual
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j. Higiene
Keterangan Sebelum sakit Saat sakit
Mandi
Ganti Pakaian
Mencuci rambut
Menggosok gigi

Keterangan:
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k. Istirahat Tidur
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l. Aktualisasi Diri
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m. Rekreasi
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n. Kebutuhan Belajar
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..
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D. Pemeriksaan Penunjang

Jenis Pemeriksaan Hasil Nilai Normal Kesan


E. Terapi Medis

Jenis Terapi Indikasi Kontraindikasi Efek Samping


F. ANALISA DATA

No Data Problem Etiologi


G. PRIORITAS DIAGNOSA KEPERAWATAN
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H. INTERVENSI

Tgl/jam Dx.Kep Tujuan & Kriteria Hasil Intervensi


I. IMPLEMENTASI
Tgl/jam No. Dx. Kep Implementasi Respon pasien Paraf
J. EVALUASI
Tgl/jam Dx. Kep Evaluasi Paraf
PEMBAHASAN

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