ASUHAN KEPERAWATAN AN........DENGAN ..............

DI RUANG ICU RSUD Hj ANNA LASMANAH BANJARNEGARA

Nama mahasiswa :
NIM :
Tanggal pengkajian :
Pukul :
A. IDENTITAS PASIEN
Nama :
Umur :
Jenis kelamin :
Pendidikan :
Pekerjaan :
Agama :
Alamat :
Diagnosa medis :
No RM :
B. IDENTITAS PENANGGUNG JAWAB
Nama :
Umur :
Jenis kelamin :
Pendidikan :
Pekerjaan :
Agama :
Alamat :
Hubungan dengan pasien :
C. PENGKAJIAN
a. Keluhan utama
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b. Riwayat penyakit sekarang
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 c. Riwayat penyakit dahulu
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d. Riwayat penyakit keluarga
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e. Riwayat pekerjaan
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f. Riwayat geografi
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g. Riwayat alergi
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h. Kebiasaan sosial
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i. Kebiasaan merokok
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D. PEMERIKSAAN FISIK
1. Keadaan umum :
2. Keluhan nyeri :
3. B1 (breathing) pernafasan
Inspeksi :
Palpasi :
Perkusi :
Auskultasi :
Rr :
Oksigenasi :
Dll :
4. B2 (blood) kardiovaskuler
Inspeksi :
Palpasi :
Perkusi :
Auskultasi :
 Heart rate :
Irama nadi :
Kualitas nadi :
Akral :
JVP :
EKG :
Dll :
5. B3 ( brain) persyarafan
Tingkat kesadaran :
GCS :
Reaksi pupil :
Reflek patologis :
Reflek fisiologis :
Dll :
6. B4 (bladeder) perkemihan
Distensi VU :
Urine :
Warna urine :
Alat bantu :
Dll :
7. B5 (bowel) pencernaan
Inspeksi :
Palpasi :
Perkusi :
Kondisi mulut :
BAB :
Alat bantu :
Dll :
8. B6 (bone) musculuskeletal
Kekuatan otot :
ROM :
Hemiplegi/parese :
Turgor :
Kelainan vertebra :
 Fraktur :
Dll :
9. Data tambahan yang mendukung analisa data
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E. PEMERIKSAAN DIAGNOSTIK
1. Pemeriksaan radiologi,tanggal
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2. EKG, tanggal
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3. AGD, tanggal
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F. PROGRAM TERAPI
Nama obat dosis Cara pemberian Waktu fungsi
pemberian
G. ANALISA DATA
TGL/ DATA (DO/DS) PENYEBAB ( E ) MASALAH ( P ) PARAF
JAM
H. PRIORITAS MASALAH
1. ....................................................................................................................................
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2. ....................................................................................................................................
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3. ....................................................................................................................................
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I. INTERVENSI
TANGGAL NO NOC NIC PARAF/
/JAM NAMA
DP
TANGGAL NO NOC NIC PARAF/
/JAM NAMA
DP
J. IMPLEMENTASI
NO DP Hari, tgl, jam Implementasi Respon
K. EVALUASI
Hari, tgl, jam Dx keperawatan SOAP