Aplikasi Proses Keperawatan Pada ..........

Di Ruang Perawatan Intensive Care Unit (ICU)

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

A. PENGKAJIAN
1. Deskripsi Pasien
Nama : .......................................................................................................
Umur : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Alamat : .......................................................................................................
No. CM : .......................................................................................................
Tanggal Masuk : .......................................................................................................
Dx. Medis : .......................................................................................................

2. Exception Summary Data

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

3. Penampilan Umum
 ......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
4. Pengkajian Terfokus
a. Anamnesa
1) Keluhan Utama
..........................................................................................................................
2) Riwayat Kesehatan Sekarang
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................

3) Riwayat Kesehatan Masa Lalu

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
4) Riwayat Kesehatan Keluarga
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
b. Pemeriksaan Fisik
1) Kesadaran : ................................................................................................
2) TTV : TD : Suhu :
Nadi : RR :
3) Terfokus
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
 ..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
5. Data Biologis
No Pola Kebiasaan Sebelum Sakit Saat Sakit Keluhan
1 Nutrisi
a. Makan
- Frekuensi
- Jenis

b. Minum
- Frekuensi
- Jenis

2 Eliminasi
a. BAK
- Frekuensi
- Warna
- Jumlah
b. BAB
- Frekuensi
- Warna
- Konsistensi

3 Personal Hygiene
a. Mandi
b. Gosok Gigi
c. Keramas

4 Istirahat dan Tidur

a. Siang

b. Malam

5 Pola Aktifitas

c. Pemeriksaan Penunjang
1) Terapi Obat
Waktu
Tanggal Nama Obat Rute Dosis
Pemberian
 2) Pemeriksaan Laboratorium
Jenis
Tanggal Hasil Nilai Normal Interpestasi
Pemeriksaan

3) Ronstgen/USG/EKG
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
B. ANALISA DATA
Data Etiologi Masalah

Data Etiologi Masalah

C. DIAGNOSA KEPERAWATAN
............................................................................................................................................
 ............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................

D. NURSING CARE PLAN

Rencana Asuhan Keperawatan ..... Di Ruang ........................................
Dibuat Tanggal .............................. Nama Perawat Primer: ..............................
Diagnosa Perencanaan
No
Keperawatan Tujuan Intervensi Rasional

Diagnosa Perencanaan
No
Keperawatan Tujuan Intervensi Rasional
 Diagnosa Perencanaan
No
Keperawatan Tujuan Intervensi Rasional
E. IMPLEMENTASI
Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................
 Data Action Respon

Evaluasi Sumatif Shiff

F. EVALUASI
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................