FORMAT ASKEP KRITIS DI RUANG ICU

I. Pengkajian
Pengkajian Keperawatan Pasien Di Nama :...............................................................
ICU No. RM :...............................................................
Jenis Kelamin : ( ) laki-laki ( ) perempuan
Tanggal: Jam:
Sumber data : ( ) pasien ( ) keluarga ( ) lainnya...................
Rujukan : ( ) tidak ( ) ya, ( ) RS ............ ( ) Puskesmas ............. ( ) dokter .........
Diagnosis :.......................................................................
Pendidikan Pasien : ( ) SD ( ) SMP ( ) SMA ( ) D3 ( ) S1 ( ) lainnya
Pekerjaan pasien : ........................

1) Keluhan Utama :
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2) Riwayat kesehatan
Riwayat kesehatan dahulu :
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 Riwayat kesehatan sekarang :
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Riwayat kesehatan keluarga :

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3) Pemeriksaan fisik
a. Sistem pernafasan
Jalan nafas:
( ) Bersih ( ) Sumbatan (Ket:........................................................)
Pernafasan:
RR:........................... x/ mnt
Penggunaan otot bantu nafas : ( ) tidak ( ) ya
Terpasang ETT : ( ) tidak ( ) ya
Terpasang ventilator : ( ) tidak ( ) ya
Mode:....................................... TV:...................................
RR:...........................................
PEEP:......................................I:E: ...................................
FiO2:..............................................
Irama : ( ) tidak teratur ( ) teratur
Kedalaman : ( ) tidak teratur ( ) teratur
Sputum : ( ) putih ( ) kuning ( ) hijau
Konsistensi : ( ) tidak kental ( ) kental
Suara nafas : ( ) ronchi ( ) wheezing
( ) vesikuler
b. Sistem Kardiovaskuler
Sirkulasi Perifer
Nadi : ...............................x/ mnt Tekanan darah :............................mmHg
Pulsasi : ( ) kuat ( ) lemah
Akral : ( ) hangat ( ) dingin Suhu ;............................0C
Warna kulit : ( ) kemerahan ( ) pucat ( ) cyanosis
Sirkulasi Jantung
Irama : ( ) tidak teratur ( ) teratur
Nyeri dada : ( ) tidak ( ) ya, Lama : ............................
Perdarahan : ( ) tidak ( ) ya Area perdarahan:........................
Jumlah : .............................cc/ jam

c. Sistem saraf pusat

Kesadaran: ( ) Composmentis ( ) Apatis ( ) Somnolent
( ) Soporocoma ( ) Koma
GCS: ............................Eye:.....................Verbal:....................Motorik:...............
Kekuatan otot:

d. Sistem Gastrointestinal
Distensi : ( ) tidak ( ) ya, lingkar perut : .......................cm
Peristaltik : ( ) tidak ( ) ya, lama: .........................x/mnt
Defekasi : ( ) tidak normal ( ) normal

e. Sistem Perkemihan
Warna : ( ) bening ( ) kuning ( ) merah ( ) kecokelatan
Distensi : ( ) tidak ( ) ya
Penggunaan catheter urin : ( ) tidak ( ) ya
No. Catheter urin:.............................
Jumlah urin: .................. cc/ jam
f. Obstetri & Ginekologi
Hamil : ( ) tidak ( ) ya, HPHT :........................
Keluhan :.................................................................................................................
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g. Sistem Hematologi
Perdarahan : ( ) gusi ( ) nasal ( ) pethecia ( ) ekimosis
Lainnya :
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h. Sistem Muskuloskeletal & Integument

Turgor kulit : ( ) tidak elastik ( ) elastik
Terdapat luka : ( ) tidak ( ) ya, Lokasi luka :............................

Fraktur : ( ) tidak ( ) ya, Lokasi fraktur:.............................

Kesulitan bergerak : ( ) tidak ( ) ya
Penggunaan alat bantu : ( ) tidak ( ) ya, Nama alat: .................................

i. Alat invasif yang digunakan

Drain/ WSD : ( ) tidak ( ) ya, Warna: ......................
Jumlah:..................cc/jam
IV Line : ( ) tidak ( ) ya
NGT : ( ) tidak ( ) ya, Warna: ......................
Jumlah:..................cc/jam
Lainnya :
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4) Riwayat psikososial & spiritual
Psikososial
Koping: ( ) menerima ( ) menolak ( ) kehilangan ( ) mandiri
Afek : ( ) gelisah ( ) insomnia ( ) tegang ( ) depresi
HDR : ( ) emosional ( ) tidak berdaya ( ) rasa bersalah
Persepsi penyakit : ( ) menerima ( ) menolak
Hubungan keluarga harmonis : ( ) tidak ( ) ya
Spritual
Kebiasaan keluarga/ pasien untuk mengatasi stres dari sisi spiritual:
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5) Resiko cedera/ jatuh

( ) tidak ( ) ya

6) Status fungsional
Aktivitas dan Mobilisasi : ( ) mandiri ( ) perlu bantuan
Alat bantu ; .................................

7) Skala Nyeri
Nyeri : ( ) tidak ( ) ya
( ) nyeri kronis, Lokasi:............................. Durasi:..........................
( ) nyeri akut, Lokasi:............................. Durasi:..........................
Score nyeri (0-10) :...................................
Nyeri hilang : ( ) minum obat ( ) istirahat ( ) mendengar musik ( ) ubah posisi
( ) Lain-lain, sebutkan:.............................................................................
Nyeri mempengaruhi: ( ) tidur ( ) aktivitas fisik ( ) emosi ( ) konsentrasi
( ) nafsu makan ( ) lainnya.................................
 8) Hasil pemeriksaan penunjang
Nama : Tanggal :

PEMERIKSAAN HASIL NILAI NORMAL INTERPRETASI

HEMATOLOGI
Hemoglobin 14,0 – 18,0 g/dl
Eritrosit 4,0 – 10,5 ribu/µl
Leukosit 4,50 – 6,00 juta/µl
Hematokrit 42.00 – 52.00 vol%
Trombosit 150 – 450 ribu/µl
RDW-CV 11,5- 14,7 %
MCV, MCH, MCHC
MCV 80-97 Fl
MCH 27-32 Pg
MCHC 32-38 %
HITUNG JENIS
Basofil % 0,0-1,0 %
Eusinofil % 1,0-3,0 %
Gran % 50,0-70,0 %
Limfosit % 25,0-40,0 %
Monisit % 3,0-9,0 %
Basofil # < 1 ribu/µl
Eusinofil # < 3 ribu/µl
Gran # 2,50-7,00 ribu/µl
Limfosit # 1,25-4,0 ribu/µl
MID # 0,30-1.00 ribu/µl
PROTHROMBIN TIME
Hasil PT 9,9-13,5 detik
INR -
Control normal PT -
Hasil APTT 22,2-37,0 detik
Control normal APTT -
KIMIA
GULA DARAH
Gula darah sewaktu < 200 mg/dl
HATI
SGOT 0-46 U/l
SGPT 0-45 U/l
GINJAL
Ureum 10-50 mg/dl
Creatinin 0,7-14 mg/dl
ELEKTROLIT
Natrium 135-146 mmol/l
Kalium 3,4-5,4 mmol/l
Clorida 95-100 mmol/l
9) Pemeriksaan Penunjang Lainnya
Analisa gas garah :.........................................................................................
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Foto thoraks :.........................................................................................
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EKG :.........................................................................................
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CT Scan :.........................................................................................
Terapi Medis/Drug Study

Nama Obat,
Frekuensi
Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Pemberian, Dosis,
Cara Pemberian
 Nama Obat,
Frekuensi
Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Pemberian, Dosis,
Cara Pemberian
 ANALISA DATA
NO. DATA PROBLEM ETIOLOGI
NO. DATA PROBLEM ETIOLOGI
PRIORITAS MASALAH KEPERAWATAN :
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RENCANA ASUHAN KEPERAWATAN
Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
IMPLEMENTASI DAN EVALUASI
DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI PARAF EVALUASI
IMPLEMENTASI DAN EVALUASI
DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI PARAF EVALUASI
 CATATAN PERKEMBANGAN
HARI/TANGGAL MASALAH / DX KEP JAM PERKEMBANGAN PARAF
 CATATAN PERKEMBANGAN
HARI/TANGGAL MASALAH / DX KEP JAM PERKEMBANGAN PARAF