ASUHAN KEPERAWATAN

I. PENGKAJIAN
Tanggal masuk :
Tanggal pengkajian :
A. Identitas Pasien
Nama :
Umur :
Alamat :
No Register :
Ruang :
Cara Pengkajian : Anamnesa, pemeriksaan fisik, catatan rekam medis
Diagnosa Medis :
Penanggung jawab :

B. Riwayat Kesehatan
1. Keluhan utama

2. Riwayat penyakit sekarang

 3. Riwayat penyakit dahulu

4. Riwayat penyakit keluarga

II. PENGKAJIAN PRIMER

Airway

Breathing

Circulation

Disability

Explosure

III. PENGKAJIAN SEKUNDER

A. Pemeriksaan fisik
 1. Keadaan Umum

2. Tanda-tanda vital
Tanggal TD Nadi RR Suhu

3. Kepala
Bentuk

mata

hidung

telinga

mulut

leher

4. Dada
Inspeksi
Palpasi
Perkusi
Auskultasi

5. Abdomen
Inspeksi
Auskultasi
Perkusi
Palpasi
 6. Ekstremitas
Ekstremitas Atas
Tanggal/ Kanan Kiri
jam Kesemutan Edema Nyeri Kesemutan Edema Nyeri

Gerak
Kekuatan Otot :
Ekstremitas Bawah

Tanggal/ Kanan Kiri

jam Kesemutan Edema Nyeri Kesemutan Edema Nyeri

Gerak
Kekuatan Otot :

7. Sistem Integumen
Mukosa Capillary
Tanggal/jam Warna kulit Turgor Kelainan
bibir refill

8. Genetalia

9. Sistem Persyarafam
a) Fungsi serebral/Status Mental
Tanggal
Status mental
 Tingkat kesadaran
 GCS
 Gaya bicara
Fungsi Intelektual
 Orientasi waktu
 Orientasi tempat
 Orientasi orang
Daya pikir
 Spontan, alamiah, masuk
akal
  Kesulitan berpikir
 Halusinasi
Status emosional
 Alamiah dan datar
 Pemarah
 Cemas
 Apatis

10. Eliminasi

11. Tingkat ketergantungan

Bathing

Dressing
Toileting
Transfering
Continence
Feeding
Indeks KATZ

12. Status Cairan

Tanggal Intake Output Balance Cairan
Parenteral : Urine :
IWL :
Feses :
Muntah :
Drainase :
Total :
Minum :
Makan :
Total :
 13. Pemeriksaan Penunjang
1) Laboratorium
Pemeriksaan Nilai Satuan
Nilai Nilai Nilai
Hb 13 - 16 %
Ht 40 - 54 %
Eritrosit 45 - 65 jt/ mmk
Leukosit 4 - 11 ribu/ mmk
Trombosit 150 - 400 ribu/mmk
Creatinin 0.6 - 1.3 mg/ dL
Albumin 3.4 - 5 mg/ dL
Gula Sewaktu 80 - 120 mg/ dL
Ureum 15 - 39 mg/ dL
Na 136 - 145 mmol/ L
K 3.5 - 5.1 mmol/ L
Cl 98 - 107 mmol/ L
Cholesterol 50 - 200 mg/ dL
Trigliserid 30 - 150 mg/ dL
Waktu 10 - 15 dtk
protrombin
PPT kontrol 12.8
Waktu 23.4 - dtk
tromboplastin 36.8
pH 7,35–3,45
pCO2 35 - 45 mmHg
pO2 83 - 103 mmHg
HCO3 18 - 23 Mmol/L
AADO2 <100
Laktat 0,4 - 2
Base Excess

14. Pemeriksaan Penunjang

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13.Therapy
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 ANALISA DATA
Nama : No CM :
Usia : Dianosa Medis :
TANGGAL DATA FOKUS ETIOLOGI MASALAH TTD
 PRIORITAS DIAGNOSA KEPERAWATAN
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 RENCANA ASUHAN KEPERAWATAN
Nama : No CM :
Usia : Diagnosa Medis :
No DIAGNOSA TUJUAN DAN KRITERIA INTERVENSI TTD
Dx. KEPERAWATAN HASIL
 IMPLEMENTASI KEPERAWATAN

TGL/JAM NO. IMPLEMENTASI RESPON TTD

DX.
 EVALUASI
Nama : No CM :
Usia : Diagnosa Medis :
TGL/JAM NO EVALUASI ( SOAP ) TTD
DX