ASUHAN KEPERAWATAN PADA TN.

S
DENGAN DIAGNOSA MEDIS STEMI INFERIOR
DI RUANG ICU RSUD CIBABAT

Oleh :
Desi Nurwijaya
NPM: 214118027

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN JENDERAL ACHMAD YANI
CIMAHI
2019
 TGL/PARAF TGL/PARAF CI NILAI RATA-
NILAI NILAI
CI KLINIK AKADEMIK RATA

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1. Pengkajian
a. Identitas Klien
Nama : ..................................................................................
Umur : ..................................................................................
Jenis Kelamin : ..................................................................................
Agama : ..................................................................................
Pendidikan : ..................................................................................
Pekerjaan : ..................................................................................
Suku/ Bangsa : ..................................................................................
Tanggal Masuk RS : ..................................................................................
Tanggal Pengkajian : ..................................................................................
No. Medrec : ..................................................................................
Diagnosa Medis : ..................................................................................
Alamat : ..................................................................................
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b. Identitas penangung jawab

Nama : ..................................................................................
Umur : ..................................................................................
Jenis kelamin : ..................................................................................
Pendidikan : ..................................................................................
Pekerjaan : ..................................................................................
Hubungan dengan klien : ..................................................................................
Alamat : ..................................................................................
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2. Riwayat Kesehatan
a. Keluhan utama
1) Keluhan Utama Saat Masuk RS :
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2) Keluhan Utama Saat Pengkajian:
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b. Riwayat Kesehatan Sekarang :
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c. Riwayat Kesehatan Dahulu
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d. Riwayat Kesehatan Keluarga
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e. Riwayat Alergi
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3. Pola Aktivitas Sehari-hari
No Jenis aktivitas Sebelum Sakit Setelah Sakit
1. Nutrisi
A. Makan
 Jenis ....................................................... .......................................................
 Frekuen ....................................................... .......................................................
si ....................................................... .......................................................
 Porsi ....................................................... .......................................................
 Keluhan
B. Minum ....................................................... .......................................................
 Jenis ....................................................... .......................................................
 Jumlah ....................................................... .......................................................
(cc/ hari)
 Keluhan
2. Eliminasi
A. BAK
 Frekuen ....................................................... .......................................................
si ....................................................... .......................................................
 Warna ....................................................... .......................................................
 Keluhan
B. BAB ....................................................... .......................................................
 Frekuen ....................................................... .......................................................
si ....................................................... .......................................................
 Warna ....................................................... .......................................................
 Konsiste
nsi
 Keluhan
 3. Istirahat Tidur
A. Siang
 Jam ....................................................... .......................................................
B. Malam
 Jam ....................................................... .......................................................
4. Personal Hygiene
A. Mandi ....................................................... .......................................................
B. Keramas ....................................................... .......................................................
C. Gosok Gigi ....................................................... .......................................................

4. Pengkajian Primer
a. Airway
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b. Breathing
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c. Circulation
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d. Dissability
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e. Exposure
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5. Pengkajian Fisik
a. Kesadaran Umum : ..............................................................................................
b. GCS : E: ....................... M:........................... V:...........................
c. Orientasi : ..............................................................................................
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d. Tanda-tanda Vital : TD : ............................ N : ..................................
RR : ............................ S : ..................................
e. Pemeriksaan Fisik
1) Kepala
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2) Mata
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3) Hidung
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4) Telinga
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5) Mulut
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6) Leher
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7) Dada
a) Paru-paru
Inspeksi : ........................................................................................................
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Palpasi
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Perkusi
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Auskultasi
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b) Jantung
Inspeksi : ........................................................................................................
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Palpasi
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 Perkusi
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Auskultasi
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8) Abdomen
Inspeksi
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Auskultasi
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Perkusi
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Palpasi
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9) Perkemihan
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10) Endoktrin
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11) Integumen
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12) Muskuloskeletal
Ekstremitas Atas
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Ektremitas Bawah
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13) Persyarafan
a) Nervus olfaktorius
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b) Nervus optikus
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c) Nervus okulomotorius
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d) Nervus trigeminus
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e) Nervus fasialis
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f) Nervus glasofaringeus
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g) Nervus vagus
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 h) Nervus asesorius
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i) Nervus hipoglosus
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6. Data Psikologis
a. Status Emosi
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b. Pola Koping
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c. Pola Komunikasi
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d. Riwayat sosial
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e. Riwayat spiritual
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7. Pemeriksaan Penunjang
a. Pemeriksaan laboratorium : tanggal
Pemeriksaan Hasil Nilai Normal

b. Pemeriksaan Laboratorium: Tanggal

Pemeriksaan Hasil Nilai Normal

c. Pemeriksaan EKG : Tanggal

8. Terapi Medis
a. Obat-Obatan
No Nama Obat Dosis Cara Tujuan Pemberian dan
Pemakaian Rasional
 b. Cairan

No Nama Cairan Jumlah Cara Tujuan Pemberian dan Rasional

Kebutuhan Pemberian

9. Analisa Data

No Data Menyimpang Etiologi Masalah

No Data Menyimpang Etiologi Masalah
10. Diagnosa Keperawatan
a. ...
b. ....

c. ....

d. ....

e. .....

f. ....
No Diagnosa Tujuan Intervensi Rasional
Keperawatan
11. Intervensi Keperawatan
12. Implementasi Dan Evaluasi
No Tgl/ Implementasi Evaluasi Paraf
Dx Jam
13. CATATAN PERKEMBANGAN
Tgl/Jam Catatan perkembangan Paraf
 STATUS FUNGSIONAL
Pengkajian status fungsional (indeks kemandirian Katz)
No Aktivitas Mandiri (Skor 1) Mandiri (Skor 0) Skor
1 Mandi Bantuan hanya pada satu bagian Bantuan lebih dari satu bagian
mandi (seperti punggung atau tubuh, bantuan masuk dan
ekstremitas yang tidak mampu) keluar dari bak mandi , seka,
atau mandi sendiri sepenuhnya tidak mandi sendiri
2 Berpakaian Mengambil baju dari lemari, Tidak dapat memakai baju
memakai pakain, melepaskan sendiri atau hanya sebagian
pakaian, mengancing/mengikat
pakaian
3 Ke kamar kecil Masuk dan keluar dari kamar Menerima bantuan untuk
kecil kemudian membersihkan masuk ke kamar kecil dan
genetalia sendiri menggunakan pispot
4 Berpindah Berpindah ke dan dari tempat Bantuan dalam naik atau turun
tidur untuk tidur bangkit dari dari tempat tidur atau kursi,
kursi sendiri tidak melakukan satu atau
lebih
5 Kontinen BAK dan BAB seluruhnya Inkontinensia parsial atau total:
dikontrol sendiri penggunaan kateter, pispot,
enema dan pembalut
(Pampers)
6 Makan Mengambil makanan dan piring Bantuan dalam hal mengambil
dan menyuapi sendiri makanan dari piring dan
menyuapinya, tidak makan
sama sekali dan makan
parenteral (NGT)

Keterangan :

Skala Braden (Patricia, 2012)

Parameter Temuan Skor
Persepsi 1. Tidak 2. Gangguan 3. Gangguan sensori 4. Tidak ada
sensori merasakan atau sensori pada pada 1 atau 2 gangguan
respon terhadap bagian ½ ekstremitas atau sensori
stimulus nyeri, permukaan berespon pada berespon
kesadaran tubuh atau perintah verbal tapi penuh
menurun hanya berespon tidak selalu mampu terhadap
pada stimuli mengatakan perintah
nyeri ketidaknyamanan verbal
Kelembapan 1. Selalu terpapar 2. Sangat lembab 3. Kadang lembab 4. Kulit
oleh keringat kering
atau urine
basah
Aktivitas 1. Terbaring di 2. Tidak bisa 3. Berjalan dengan 4. Dapat
tempat tidur berjalan atau tanpa berjalan
bantuan sekitar
ruangan
Mobilitas 1. Tidak mampu 2. Tidak dapat 3. Dapat membuat 4. Dapat
bergerak merubah posisi perubahan posisi merubah
secara tepat tubuh posisi
dan teratur tanpa
bantuan
Nutrisi 1. Tidak dapat 2. Jarang mampu 3. Mampu 4. Dapat
menghabiskan menghabiskan menghabiskan menghasil
1/3 porsi ½ porsi lebih dari ¼ porsi kan porsi
makannnya makanannya makannya makannya
sedikit minum, atau intake , tidak
puasa atau cairan kurang memerluk
minum air dari jumlah an
putih atau optimum suplemen
mendapat infus nutrisi
lebih dari 5
hari
Gesekan 1. Tidak mampu 2. Membutuhkan 3. Membutuhkan
mengangkat bantuan bantuan minimal
badannya minimal mengangkat
sendiri, atau mengangkat tubuhnya
spasifik, tubuhnya
kontraktor atau
gelisah

Analisa skor skala Braden yang didapat dengan kriteria :

1. Resiko ringan jika skor 15-23
2. Resiko sedang jika skor 13-14
3. Resiko berat jika skor 10-12
4. Resiko sangat berat jika skoring kurang dari 10