Asuhan

Keperawatan
Profesi KGD
Nama Mahasiswa

Kasus/Diagnosa Medis :
Jenis Kasus : Trauma / Non Trauma/ICU
Ruangan :
Kasus ke :

CATATAN KOREKSI PEMBIMBING

KOREKSI I KOREKSI II

(………………………………………………………..………...………) (……………………..…………...……………………………………...)
 FORMAT ASUHAN KEPERAWATAN GAWAT
DARURAT (Intensive Care Unit)

Tanggal Rawat : ……………………….. No.Medrec : ………………………..

Tanggal Pengkajian : ……………………….. Diagnosa Medis : ………………………..

A. IDENTITAS KLIEN
Nama : ………………………..

Umur : ………………………..

Jenis kelamin : ………………………..

Pendidikan : ………………………..

Pekerjaan : ………………………..

Agama : ………………………..

Status Marital : ………………………..

Suku / Bangsa : ………………………..

Alamat :……………………………………………………………………………………………………………………..………………………………………

……………………………………………………………………………………………………………………………………………………………..

B. IDENTITAS PENANGGUNG JAWAB

Nama : ………………………..

Umur : ………………………..

Jenis Kelamin : ………………………..

Pekerjaan : ………………………..

Alamat : …………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………….…………………………………………….

Hubungan Dengan Klien :.......................................................................................................................................................………………………………..

C. RIWAYAT KESEHATAN

1. Alasan Masuk ICU

……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
…………………………

2. Keluhan Utama
…………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………….………………………………
………………………………………………………………………………………………………………….

3. Riwayat Kesehatan Sekarang

……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
…………

4. Riwayat Kesehatan Dahulu

……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
…………………………………….

5. Riwayat Kesehatan Keluarga

………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..

D. KEMAMPUAN PERAWATAN DIRI

1. Feeding  Mandiri  Dibantu  Total Care

2. Toileting  Mandiri  Dibantu  Total Care
3. Bathing  Mandiri  Dibantu  Total Care
4. Grooming  Mandiri  Dibantu  Total Care

E. SCORE SKALA BRADEN : …………………………………………….

INTERPRESTASI HASIL :……………………………………………

F. PEMERIKSAAN FISIK
1. Kesadaran : ……………………..
2. Tanda Vital
a. Suhu :……………………..
b. Tekanan Darah :……………………..
c. Nadi :……………………..
d. Respirasi : ……………………..
e. Saturasi O2 : ……………………..
 Asuhan Keperawatan Profesi KGD 2018-2019

3. Data pengkajian fisik fokus

4. Hasil Pemeriksaan Diagnostik

…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………….
5. Program Terapi:
a. Nutrisi :
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………..

Format Asuhan Keperawatan

 Asuhan Keperawatan Profesi KGD 2018-2019

b. Cairan :
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………..
c. Obat obatan :
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………….
6. Pennggunaan alat bantu:
 Bedside Monitor
 Infusion Pump (jenis cairan……………….., kecepatan aliran……………. Penambahan obat
………………………..……………, dosis obata………………….)
 Syringe Pump (jenis obat…………………………., Kecepatan aliran…………………….)
 Ventilator (Setting:......................................................................................................................)
 ………………………….

DATA PENGETAHUAN
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………..

DATA PSIKOSOSIAL SPIRITUAL

………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………..

Format Asuhan Keperawatan

 Asuhan Keperawatan Profesi KGD 2018-2019

ANALISA DATA

DATA ETIOLOGI DIAGNOSA KEPERAWATAN

Diagnosa Keperawatan berdasarkan prioritas:

1. …………………………………………………………………………………………………………………………………………………………
2. …………………………………………………………………………………………………………………………………………………………

Format Asuhan Keperawatan

NURSING CARE PLAN

Nama Pasien:……………………………….. Umur :……………..tahun No Medrek:…………………………….. Diagnosa Medis:………………………….

TUJUAN DAN KRITERIA INTERVENSI AKTIVITAS

DX. KEPERAWATAN
(NOC) (NIC DOMAIN) (NIC)
IMPLEMENTASI DAN EVALUASI

Nama Pasien : Usia:

No Medrek : Diagnosa Medis:

NO. DX TANGGAL IMPLEMENTASI EVALUASI PARAF

 CATATAN PERKEMBANGAN ASUHAN KEPERAWATAN

Nama Pasien : Usia:

No Medrek : Diagnosa Medis:

Tanggal No Diagnosa Catatan Perkembangan Paraf

( SOAPIE )
 Asuhan Keperawatan Profesi KGD 2018-2019

LAMPIRAN LEMBAR MONITORING ICU

*Lampirkan Lembar observasi Monitoring ICU

Format Asuhan Keperawatan