Program Studi S1 Keperawatan STIKES Advaita Medika

Asuhan Keperawatan Intensif

Pada Pasien Tn/Ny/An......... Dengan..............................

Diruang.........................RSUP Sanglah

Tanggal........................

Tgl/Jam : No RM :

Ruangan : Diagnosa Medis :

Nama/Inisial : Jenis Kelamin :

Umur : Status Perkawinan :

Agama : Sumber Informasi :

IDENTITAS

Pendidikan : Hubungan :

Pekerjaan :

Suku/Bangsa :

Alamat :

Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

Keluhan utama saat MRS :..................................................................................................

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Keluhan utama saat pengkajian :......................................................................................
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Riwayat penyakit saat ini :..................................................................................................
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Riwayat alergi : ..................................................................................................................
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RIWAYAT SAKIT DAN KESEHATAN

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Riwayat pengobatan :........................................................................................................
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Riwayat penyakit sebelumnya dan riwayat penyakit keluarga :
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Praktik..............................................................................................................................................
Klinik Keperawatan Intensif
 Program Studi S1 Keperawatan STIKES Advaita Medika

Jalan nafas : ( ) Paten ( ) Tidak paten

Obstruksi : ( ) lidah ( ) cairan ( ) benda asing ( ) tidak ada

( ) muntahan ( ) darah ( ) odema

Suara nafas : ( ) snoring ( ) gurgling ( ) stidor ( ) tidak ada

Nafas : ( ) spontan ( ) tidak spontan

Gerakan dinding dada : ( ) simetris ( ) asimetris

Irama nafas : ( ) cepat ( ) dangkal ( ) normal

Pola nafas : ( ) teratur ( ) tidak teratur

Jenis : ( ) dispnoe ( ) kusmaul ( ) cyene stoke

( ) lain-lain

Suara nafas : ( ) vesikuler ( ) stidor ( ) whezing ( ) ronchi

Sesak nafas : ( ) ada ( ) tidak ada

Cuping hidung : ( ) ada ( ) tidak ada

BREATHING

Retraksi otot bantu nafas : ( )ada ( ) tidak ada

Pernafasan : ( ) pernafasan dada ( ) pernafasan perut

Batuk : ( ) ya ( ) tidak ada

Sputum : ( ) ya, warna :......................... konsistensi :........................

Volume :............................ Bau : ............................ ( ) tidak ada

RR : x/menit

Alat bantu nafas : ( ) OTT ( ) ETT ( ) trakeostomi ( )

ventilator
Keterangan : ...................................................................................................................

Oksigenasi : liter/menit, ( ) nasal kanul ( ) simple mask ( ) non

RBT mask ( ) RBT mask ( ) tidak ada
Lain-lain : ............................................................................................................................

Masalah Keperawatan :
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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

Nadi : ( ) teraba ( ) tidak teraba ( )N x/menit

Tekanan darah : mmHg

Pucat : ( ) ya ( ) tidak

Sianosis : ( ) ya ( ) tidak

CRT : ( ) <2 detik ( ) >2 detik

O
Akral : ( ) hangat ( ) dingin ( )S: C

Perdarahan : ( ) ya, lokasi : .................................................. jumlah : ............... cc

( ) tidak
BLOOD

Turgor : ( ) elastis ( ) lambat

Diaphoresis : ( ) ya, ( ) tidak

Riwayat kehiangan cairan berlebihan : ( ) diare ( ) muntah ( ) luka

bakar

IVFD : ( ) ya ( ) tidak jenis cairan : ...........................................

Lain-lain : ..............................................................................................................................

Masalah keperawatan : ........................................................................................................

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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

Kesadaran : ( ) composmentis ( ) delirium ( ) somnolen ( ) apatis

( ) koma

GCS : ( ) eye............ ( ) verbal..............( ) motorik......................

Pupil : ( ) isokor ( ) unisokor ( ) pinpoint ( ) medriasis

Refleks cahaya : ( ) ada ( ) tidak ada

Reflek fisiologis : ( ) patela (+/-) ( )lain-lain : ....................................................

Reflek pada bayi : ( ) reflek rooting (+/-) ( ) refleks moro(+/-) (khusus

PICU/NICU) ( ) refleks sucking (+/-) ( ) lain-lain
BRAIN

:..........................................

Bicara : ( ) lancar ( ) cepat ( ) lambat

Tidur malam : ............jam, Tidur siang : ................jam

Ansietas : ( ) ada ( ) tidak ada

Lain-lain : .............................................................................................................................

Masalah keperawatan : .......................................................................................................

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Nyeri pinggang : ( ) ada ( ) tidak ada

BAK : ( ) lancar ( ) inkontenensia ( ) anuri

Nyeri BAK : ( ) ada ( ) tidak ada

Frekuensi BAK : .......................warna : ................................... darah :

...............................
BLADDER

( ) ada ( ) tidak ada

Kateter : ( ) ada ( ) tidak ada, urine output :

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Lain-lain : .........................................................................

Masalah keperawatan : ........................................................................................................

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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

TB : ..........cm BB : ...........kg

Nafsu makan : ( ) mual ( ) muntah ( ) sulit menelan

Makan : frekuensi ..................x/menit, Jumlah : ................porsi

Minum : frekuensi .................x/menit, Jumlah : ..................cc/hr

Perut kembung : ( ) ya ( ) tidak ada

BOWEL

BAB : ( ) teratur ( ) tidak

Frekuensi BAB : .....................x/mnt. Konsistensi :............................ warna

:......................
( ) darah (+/-) ( ) lendir (+/-)
Lain-lain : ...........................................................................................

Masalah keperawatan : .......................................................................................................

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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

Nyeri : ( ) ada ( ) tidak ada

Problem :..............................................................................................................................
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Qualitas/quantitas : ............................................................................................................
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Regio : .................................................................................................................................
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BONE ( Muskuloskeletal dan Integument )

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Skala : ..................................................................................................................................
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Kekuatas otot : ....................................................................................................................
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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

Deformitas : ( ) ya ( ) tidak ( ) lokasi

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Contusio : ( ) ya ( ) tidak ( ) lokasi

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Abrasi : ( ) ya ( ) tidak ( ) lokasi :....................................................

Pentrasi : ( ) ya ( ) tidak ( ) lokasi :....................................................

Laserasi : ( ) ya ( ) tidak ( ) lokasi :....................................................

Edema : ( ) ya ( ) tidak ( ) lokasi :....................................................

Luka bakar : ( ) ya ( ) tidak ( ) lokasi

:......................................................
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Grade : ......................%

Jika ada luka/vulnus, kaji :

Luas luka : ............................................................................................................................

Warna dasar luka : ..............................................................................................................

Kedalaman : ........................................................................................................................

Aktivitas : ( ) 0 ( )1 ( )2 ( )3 ( )4
Makan/Minum : ( ) 0 ( )1 ( )2 ( )3 ( )4
Mandi : ( ) 0 ( )1 ( )2 ( )3 ( )4
Toileting : ( ) 0 ( )1 ( )2 ( )3 ( )4
Berpakaian : ( ) 0 ( )1 ( )2 ( )3 ( )4
Mobilisasi di tempat tidur ( ) 0 ( )1 ( )2 ( )3 ( )4
Berpindah : ( ) 0 ( )1 ( )2 ( )3 ( )4
Ambulasi : ( ) 0 ( )1 ( )2 ( )3 ( )4
Lain-lain :...............................................................................................................................
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Masalah keperawatan : .......................................................................................................

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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

(fokus pemeriksaan pada daerah trauma/ sesuai kasus non trauma)

Kepala wajah :
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Leher :
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Dada :
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HEAD TO TOE

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Abdomen dan pinggang :
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Pelvis dan perineum :
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Ekstremitas :
Atas :
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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

Bawah :
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Masalah keperawatan : .......................................................................................................
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Hasil Laboratorium : tanggal ................................
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TEST DIAGNOSTIK DAN TERAPI MEDIS

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Praktik Klinik Keperawatan Intensif

 Program Studi S1 Keperawatan STIKES Advaita Medika

Terapi medis saat ini : tanggal......................................

No Nama Obat Dosis Rute

1

3
TEST DIAGNOSTIK DAN TERAPI MEDIS

10

11

12

13

14

15

Praktik Klinik Keperawatan Intensif