ASUHAN KEPERAWATAN

PADA PASIEN ................................................................

DENGAN DIAGNOSA MEDIS ..............................
DI RUANG .............................................

DEPARTEMEN

KEPERAWATAN KRITIS

Disusun Oleh:

...............................................

PROGRAM STUDI S1 KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA
JOMBANG
2019

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

 PENGALAMAN BELAJAR RAKTIKA
PROGRAM STUDI S1 KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA JOMBANG
Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886
Email: stikes.icme@yahoo.com

Asuhan Keperawatan pada pasien ................................

Dengan Diagnosa Medis .................................
di Ruang...........................................

I. PENGKAJIAN
A. Tanggal Masuk : ......................................................................................................................
B. Jam masuk : ......................................................................................................................
C. Tanggal Pengkajian : ......................................................................................................................
D. Jam Pengkajian : ......................................................................................................................
E. No.RM : ......................................................................................................................
F. Identitas
1. Identitas pasien
a. Nama :.............................................................................................................
b. Umur :.............................................................................................................
c. Jenis kelamin :.............................................................................................................
d. Agama :.............................................................................................................
e. Pendidikan :.............................................................................................................
f. Pekerjaan :.............................................................................................................
g. Alamat :.............................................................................................................
h. Status Pernikahan :.............................................................................................................
2. Penanggung Jawab Pasien
a. Nama :.............................................................................................................
b. Umur :.............................................................................................................
c. Jenis kelamin :.............................................................................................................
d. Agama :.............................................................................................................
e. Pendidikan :.............................................................................................................
f. Pekerjaan :.............................................................................................................
g. Alamat :.............................................................................................................
h. Hub. Dengan PX :.............................................................................................................

G. Pengkajian
1. Primary Survey
a. Airway
1) Posisi kepala : .....................................................................................................................
2) Secret/sputum : ...................................................................................................................
Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019
 3) Reflek batuk : .....................................................................................................................
4) Lidah jatuh :........................................................................................................................
5) Benda asing : ......................................................................................................................
6) Gigi : ...................................................................................................................................
7) Epistaksis : ..........................................................................................................................
8) Data lain : ...........................................................................................................................
b. Breathing
1) Frekuensi nafas : .................................................................................................................
2) Irama nafas : .......................................................................................................................
3) Suara nafas : .......................................................................................................................
4) Kedalaman nafas : ..............................................................................................................
5) Pola nafas : .........................................................................................................................
6) Jenis pernafasan :................................................................................................................
7) Suara tambahan : ................................................................................................................
8) Ekspansi dada : ...................................................................................................................
9) Batuk : ................................................................................................................................
10) Data lain : ...........................................................................................................................
c. Circulation
1) Tekananan darah : ..............................................................................................................
2) Bunyi jantung : ...................................................................................................................
3) Akral : .................................................................................................................................
4) Sianosis :.............................................................................................................................
5) CRT : ..................................................................................................................................
6) Suhu : ..................................................................................................................................
7) Odem : ................................................................................................................................
8) Tremor : ..............................................................................................................................
9) Data lain : ...........................................................................................................................
d. Disability
1) Kesadaran : .........................................................................................................................
2) GCS : ..................................................................................................................................
3) Respon nyeri : .....................................................................................................................
4) Respon bicara : ...................................................................................................................
5) Reflek pupil : ......................................................................................................................
6) Spasme otot: .......................................................................................................................
7) Parastesia : ..........................................................................................................................
8) ROM : .................................................................................................................................
9) Data lain .............................................................................................................................
e. Exposure
1) Cedera :...............................................................................................................................
2) Kerusakan jaringan : ...........................................................................................................

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

 3) Dislokasi : ...........................................................................................................................
4) Luka : ..................................................................................................................................
5) Odem : ................................................................................................................................
6) Data lain : ...........................................................................................................................
............................................................................................................................................

2. Secondary Survey
a. Keadaan Umum
a. Status gizi : Gemuk Normal Kurus
Berat Badan ...................................... Tinggi Badan : ...............................................
b. Sikap : Tenang Gelisah Menahan nyeri
b. Pemeriksaan Fisik
1) Breathing (B1)
a. Bentuk dada: .................................................................................................................
b. Frekuensi nafas : ...........................................................................................................
c. Kedalaman nafas : ........................................................................................................
d. Jenis pernafasan :..........................................................................................................
e. Pola nafas : ...................................................................................................................
f. Retraksi otot bantu : .....................................................................................................
g. Irama nafas : .................................................................................................................
h. Ekspansi paru : .............................................................................................................
i. Vocal fremitus : ............................................................................................................
j. Nyeri : ...........................................................................................................................
k. Batas paru : ...................................................................................................................
l. Suara nafas : .................................................................................................................
m. Suara tambahan : ..........................................................................................................
n. Pemeriksaan penunjang : ..............................................................................................
......................................................................................................................................
o. Data lain : .....................................................................................................................
......................................................................................................................................
2) Blood (B2)
a. Ictus cordis : .................................................................................................................
b. Nyeri : ...........................................................................................................................
c. Batas jantung : ..............................................................................................................
d. Bunyi jantung : .............................................................................................................
e. Suara tambahan : ..........................................................................................................
f. Pemeriksaan penunjang : ..............................................................................................
......................................................................................................................................
g. Data lain : .....................................................................................................................
......................................................................................................................................

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

 3) Brain (B3)
a. Kesadaran : ...................................................................................................................
b. GCS : ...........................................................................................................................
c. Reflek fisiologis : .........................................................................................................
d. Reflek patologis :..........................................................................................................
e. Pemeriksaan penunjang : ..............................................................................................
......................................................................................................................................
f. Data lain : .....................................................................................................................
......................................................................................................................................
4) Bladder (B4)
a. Kebiasaan miksi : .........................................................................................................
b. Pola miksi : ...................................................................................................................
c. Warna urine : ................................................................................................................
d. Jumlah urine : ...............................................................................................................
e. Pemeriksaan penunjang : ..............................................................................................
......................................................................................................................................
f. Data lain : .....................................................................................................................
......................................................................................................................................
5) Bowel (B5)
a. Bentuk abdomen : .........................................................................................................
b. Kebiasaan defekasi : .....................................................................................................
c. Pola defekasi : ..............................................................................................................
d. Warna feses : ................................................................................................................
e. Kolostomi : ...................................................................................................................
f. Bising usus : .................................................................................................................
g. Pemeriksaan penunjang : ..............................................................................................
......................................................................................................................................
h. Data lain : .....................................................................................................................
......................................................................................................................................
6) Bone (B6)
a. Kekuatan otot: ..............................................................................................................
b. Turgor : .........................................................................................................................
c. Odem : ..........................................................................................................................
d. Nyeri : ...........................................................................................................................
e. Warna kulit : .................................................................................................................
f. Akral : ...........................................................................................................................
g. Sianosis :.......................................................................................................................
h. Parese : .........................................................................................................................
i. Alat bantu : ...................................................................................................................
j. Pemeriksaan penunjang : ..............................................................................................

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

 ......................................................................................................................................
k. Data lain : .....................................................................................................................
.....................................................................................................................................

c. Terapi Medik
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

II. ANALISA DATA
NO. DATA ETIOLOGI MASALAH

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

III. DIAGNOSA KEPERAWATAN (SESUAI PRIORITAS)
1. ........................................................................................................................................................
........................................................................................................................................................
2. ........................................................................................................................................................
........................................................................................................................................................
3. ........................................................................................................................................................
........................................................................................................................................................
4. ........................................................................................................................................................
........................................................................................................................................................
5. ........................................................................................................................................................
........................................................................................................................................................

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

IV. RENCANA TINDAKAN KEPERAWATAN

NO. DIAGNOSA NOC NIC

KEPERAWATAN (SMART)
SMART: Label NIC :

Aktifitas Keperawatan :

Label NOC :

Indikator :
Indeks
No. Indikator
1 2 3 4 5

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

V. IMPLEMENTASI
NO. HARI/ JAM TINDAKAN KEPERAWATAN PARAF
DX TGL

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019

VI. EVALUASI
NO. NO. DX HARI/ JAM EVALUASI PARAF
TGL (SOAP)

Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019