ASUHAN KEPERAWATAN KRITIS

Nama : Tn. A
Usia : 21 Thn
Alamat :
No. Register : x-xx-xx- 76
Kriteria Klien :
Tanggal MRS : 24 Juni 2019
Tanggal Pengkajian : 24 Juni 2019

I. PENGKAJIAN
1. Keluhan Utama
Pasien mengalami penurunan kesadaran

2. Riwayat Penyakit
a. Riwayat Penyakit Sekarang
Pasien datang dengan keluhan nyeri pada leher setelah kecelakan selama ± 21 jam
sebelum masuk rumah sakit, pasien mengendarai sepeda motor tanpa helm. Pasien
menabrak mobil yang sedang mundur sehingga pasien terjatuh. Pasien mengalami
kesulitan bernapas dan muntah darah lebih dari 5 kali pada malam hari serta trakhir batuk
darah sebelum masuk rumah sakit
b. Riwayat Penyakit Dahulu
Keluarga mengatakan pasien tidak langsung dibawa kerumah sakit karna merasa tidak
apa apa, setelah pasien muntah darah baru keluarga membawa kerumah sakit.
c. Riwayat Penyakit Keluarga
Keluarga mengatakan tidak ada riwayat keturunan darah tinggi, gula darah, dan asma
d. Diagnosa Medis
Trauma tumpul regio colli susp. Trauma laryng + Emphisema subcutis regio colli +
CKR + Aspirasi Pneuonia + Gagal napas.

3. Secondary Survey
a. B1 (Breath)
Inspeksi : Tidak ada jejas, bentuk dada normo chest, tidak ada otot bantu napas
Palpasi : Ekspansi paru simetris, teraba krepitasi kiri dan kanan, tidak ada nyeri
tekan
Perkusi : terdengar redup pada paru kanan
Auskultasi : Terdengar ronkhi
b. B2 (Blood)
Inspeksi : Iktus kordis tidak terlihat, tidak ada sianosis
Palpasi : PMI teraba namun tidak kuat angkat, CTR < 2 detik
Perkusi : Terdengar redup pada batas jantung
Auskultasi : Suara jantung S1 dan S2 tunggal
TTV : TD : 150/80 mmHg
N : 122x/m
RR : 28x/m
T : 36,7 0C
MAP : 103,3 mmHg
SpO2 : 97% dengan O2 15 Lpm +ETT

c. B3 (Brain)
Paien mengalami penurunan kesadaran dengan ramsey score R4

d. B4 (Bowel)
Inspeksi : tidak ada distensi, tidak ada jejas,
Auskultasi : bising usus 8x/m
Perkusi : terdengar timpani
Palpasi : tidak ada massa,

e. B5 (Bladder)
Inspeksi : pasien terpasang kateter dengan urin kuning keruh

f. B6 (Bone)
Inspeksi : tidak ada jejas pada ekstremitas atas dan bawah, tidak ada kelemahan
pada ekstremitas atas dan bawah, pasienter pasang restrain pada
ekstremitas atas dan bawah
Skala otot :
4444 4444 ket : 0 : Tidak ada pergerakan otot
4444 4444 1 : Ada kontraksi
2 : Tidak dapat melawan gravitasi
3 : Dapat melawan gravitasi
4 : Mampu menahan tekanan ringan
5 : Mampu menahan tekanan berat.
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)
DS : - Hipoventilasi Gangguan perfusi jaringan serebral

DO :
- Pasien terpasang ETT
- Pasien dengan penurunan kesadaran
- MAP 103,3
- ramsey score R4
TTV :
TD : 150/80 mmHg
N : 122x/m
RR : 28x/m
T : 36,7 0C
SpO2 : 97% dengan O2 15 Lpm
+ETT
DS : - obstruksi jalan nafas oleh Ketidakefektifan bersihan jalan napas
DO : secret
 Pasien terpasang ETT
 Pasien mengalami penurunan
kesadaran
 Adanya secret dipada jalan nafas
 Terdengar ronkhi pada paru kanan
 Terdengar sonor pada paru kanan
DS : PK Infeksi

DO :
- Pasien terpasang kateter
- Pasien terpasang ETT
- Pasien terpasang infus
- Pasien terpasang NGT
- Leukosit 17,4 ribu/Ul
III. PRIORITAS DIAGNOSA KEPERAWATAN
1. Gangguan perfusi jaringan serebral b.d Hipoventilasi
2. Ketidakefektifan bersihan jalan napas b.d obstruksi jalan nafas oleh secret
3. PK Infeksi
IV. RENCANA KEPERAWATAN
No Diagnosa Keperawatan
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Tujuan dan Kriteria Hasil Intervensi
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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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VI. CATATAN OBSERVASI
No Diagnosa Keperawatan Tanggal/Jam
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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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