ASUHAN KEPERAWATAN KRITIS

Nama : ……………………………………………………………..
Usia : ……………………………………………………………..
Alamat : ……………………………………………………………..
No. Register : ……………………………………………………………..
Kriteria Klien : ……………………………………………………………..
Tanggal MRS : ……………………………………………………………..
Tanggal Pengkajian : ……………………………………………………………..

I. PENGKAJIAN
1. Keluhan Utama
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2. Riwayat Penyakit
a. Riwayat Penyakit Sekarang
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 b. Riwayat Penyakit Dahulu
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c. Riwayat Penyakit Keluarga

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d. Diagnosa Medis
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3. Secondary Survey
a. B1 (Breath)
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b. B2 (Blood)
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c. B3 (Brain)
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d. B4 (Bowel)
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e. B5 (Bladder)
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f. B6 (Bone)
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4. Pemeriksaan Penunjang
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5. Terapi Farmakologi
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Banjarmasin, 2018

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II. ANALISA DATA
No Data (Symptom) Penyebab (Etiologi) Masalah (Problem)
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No Data (Symptom) Penyebab (Etiologi) Masalah (Problem)
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III. PRIORITAS DIAGNOSA KEPERAWATAN
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IV. RENCANA KEPERAWATAN
No Diagnosa Keperawatan
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Tujuan dan Kriteria Hasil Intervensi
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No Diagnosa Keperawatan
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Tujuan dan Kriteria Hasil Intervensi
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V. IMPLEMENTASI
No Tanggal/Jam Tindakan Keperawatan Paraf

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No Tanggal/Jam Tindakan Keperawatan Paraf

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VI. CATATAN OBSERVASI
No Diagnosa Keperawatan Tanggal/Jam
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Catatan Observasi (SOAPIE)
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Catatan Observasi (SOAPIE)
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VII. CATATAN PERKEMBANGAN
No Diagnosa Keperawatan Tanggal/Jam Evaluasi (SOAP)

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 PEMERIKSAAN PENUNJANG

Jika Ada Pemeriksaan Baru Setelah Pengkajian

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