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ASUHAN KEPERAWATAN DI RUANG ICU

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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ANALISA DATA
Nama : No CM :
Usia : Dianosa
Medis :
TANGGAL DATA FOKUS ETIOLOGI

PRIORITAS DIAGNOSA KEPERAWATAN


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RENCANA ASUHAN KEPERAWATAN


Nama : No CM :
Usia : Diagnosa
Medis :
No DIAGNOSA TUJUAN DAN KRITERIA INTERVENSI
Dx. KEPERAWATAN HASIL
IMPLEMENTASI KEPERAWATAN

TGL/JAM NO. IMPLEMENTASI RES


DX.

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