ASUHAN KEPERAWATAN

PADA PASIEN ................................................................

DENGAN DIAGNOSA MEDIS ..............................
DI RUANG .............................................

DEPARTEMEN

KEPERAWATAN KRITIS

Disusun Oleh:

...............................................

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA
JOMBANG
2019

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
 PENGALAMAN BELAJAR PROFESI
PROGRAM STUDI PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA JOMBANG
Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886
Email: stikes.icme@yahoo.com

Asuhan Keperawatan pada pasien ................................

Dengan Diagnosa Medis .................................
di Ruang ...........................................

I. PENGKAJIAN
A. Tanggal Masuk :.........................................................................................................
B. Jam masuk :.........................................................................................................
C. Tanggal Pengkajian :.........................................................................................................
D. Jam Pengkajian :.........................................................................................................
E. No.RM :.........................................................................................................
F. Identitas
1. Identitas pasien
a. Nama : ...............................................................................................
b. Umur : ...............................................................................................
c. Jenis kelamin : ...............................................................................................
d. Agama : ...............................................................................................
e. Pendidikan : ...............................................................................................
f. Pekerjaan : ...............................................................................................
g. Alamat : ...............................................................................................
h. Status Pernikahan : ...............................................................................................
2. Penanggung Jawab Pasien
a. Nama : ...............................................................................................
b. Umur : ...............................................................................................
c. Jenis kelamin : ...............................................................................................
d. Agama : ...............................................................................................
e. Pendidikan : ...............................................................................................
f. Pekerjaan : ...............................................................................................
g. Alamat : ...............................................................................................
h. Hub. Dengan PX : ...............................................................................................

G. Pengkajian
1. Primary Survey
a. Airway
1) Posisi kepala : .......................................................................................................
2) Secret/sputum :......................................................................................................
Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
 3) Reflek batuk : ........................................................................................................
4) Lidah jatuh : ..........................................................................................................
5) Benda asing : .........................................................................................................
6) Gigi : .....................................................................................................................
7) Epistaksis : ............................................................................................................
8) Data lain : ..............................................................................................................
b. Breathing
1) Frekuensi nafas : ...................................................................................................
2) Irama nafas : ..........................................................................................................
3) Suara nafas : ..........................................................................................................
4) Kedalaman nafas : .................................................................................................
5) Pola nafas : ............................................................................................................
6) Jenis pernafasan : ..................................................................................................
7) Suara tambahan : ...................................................................................................
8) Ekspansi dada : .....................................................................................................
9) Batuk : ...................................................................................................................
10) Data lain : ..............................................................................................................
c. Circulation
1) Tekananan darah : .................................................................................................
2) Bunyi jantung : ......................................................................................................
3) Akral : ...................................................................................................................
4) Sianosis : ...............................................................................................................
5) CRT :.....................................................................................................................
6) Suhu : ....................................................................................................................
7) Odem : ...................................................................................................................
8) Tremor : ................................................................................................................
9) Data lain : ..............................................................................................................
d. Disability
1) Kesadaran :............................................................................................................
2) GCS :.....................................................................................................................
3) Respon nyeri : .......................................................................................................
4) Respon bicara : ......................................................................................................
5) Reflek pupil :.........................................................................................................
6) Spasme otot: ..........................................................................................................
7) Parastesia : ............................................................................................................
8) ROM : ...................................................................................................................
9) Data lain ................................................................................................................
e. Exposure
1) Cedera : .................................................................................................................
2) Kerusakan jaringan : .............................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
 3) Dislokasi : .............................................................................................................
4) Luka : ....................................................................................................................
5) Odem : ...................................................................................................................
6) Data lain : ..............................................................................................................
...............................................................................................................................

2. Secondary Survey
a. Keadaan Umum
a. Status gizi : Gemuk Normal Kurus
Berat Badan ........................ : Tinggi Badan : ........................
b. Sikap : Tenang Gelisah Menahan nyeri
b. Pemeriksaan Fisik
1) Breathing (B1)
a. Bentuk dada: ...................................................................................................
b. Frekuensi nafas : .............................................................................................
c. Kedalaman nafas : ...........................................................................................
d. Jenis pernafasan : ............................................................................................
e. Pola nafas : ......................................................................................................
f. Retraksi otot bantu : ........................................................................................
g. Irama nafas : ....................................................................................................
h. Ekspansi paru : ................................................................................................
i. Vocal fremitus :...............................................................................................
j. Nyeri : .............................................................................................................
k. Batas paru : .....................................................................................................
l. Suara nafas : ....................................................................................................
m. Suara tambahan : .............................................................................................
n. Pemeriksaan penunjang : ................................................................................
.........................................................................................................................
o. Data lain : ........................................................................................................
.........................................................................................................................
2) Blood (B2)
a. Ictus cordis : ....................................................................................................
b. Nyeri : .............................................................................................................
c. Batas jantung :.................................................................................................
d. Bunyi jantung : ................................................................................................
e. Suara tambahan : .............................................................................................
f. Pemeriksaan penunjang : ................................................................................
.........................................................................................................................
g. Data lain : ........................................................................................................
.........................................................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
 3) Brain (B3)
a. Kesadaran :......................................................................................................
b. GCS : ..............................................................................................................
c. Reflek fisiologis : ............................................................................................
d. Reflek patologis : ............................................................................................
e. Pemeriksaan penunjang : ................................................................................
.........................................................................................................................
f. Data lain : ........................................................................................................
.........................................................................................................................
4) Bladder (B4)
a. Kebiasaan miksi : ............................................................................................
b. Pola miksi : .....................................................................................................
c. Warna urine :...................................................................................................
d. Jumlah urine : ..................................................................................................
e. Pemeriksaan penunjang : ................................................................................
.........................................................................................................................
f. Data lain : ........................................................................................................
.........................................................................................................................
5) Bowel (B5)
a. Bentuk abdomen : ...........................................................................................
b. Kebiasaan defekasi : .......................................................................................
c. Pola defekasi : .................................................................................................
d. Warna feses : ...................................................................................................
e. Kolostomi :......................................................................................................
f. Bising usus : ....................................................................................................
g. Pemeriksaan penunjang : ................................................................................
.........................................................................................................................
h. Data lain : ........................................................................................................
.........................................................................................................................
6) Bone (B6)
a. Kekuatan otot: .................................................................................................
b. Turgor : ...........................................................................................................
c. Odem : .............................................................................................................
d. Nyeri : .............................................................................................................
e. Warna kulit : ...................................................................................................
f. Akral : .............................................................................................................
g. Sianosis : .........................................................................................................
h. Parese : ............................................................................................................
i. Alat bantu : ......................................................................................................
j. Pemeriksaan penunjang : ................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
 .........................................................................................................................
k. Data lain : ........................................................................................................
........................................................................................................................

c. Terapi Medik
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
II. ANALISA DATA
NO. DATA ETIOLOGI MASALAH

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
III. DIAGNOSA KEPERAWATAN (SESUAI PRIORITAS)
1. ....................................................................................................................................
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2. ....................................................................................................................................
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3. ....................................................................................................................................
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4. ....................................................................................................................................
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5. ....................................................................................................................................
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Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
 IV. RENCANA TINDAKAN KEPERAWATAN

NO. DIAGNOSA NOC NIC

KEPERAWATAN
Label NOC : Label NIC :

Indikator : Aktifitas Keperawatan :

Indeks
No. Indikator
1 2 3 4 5

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
V. IMPLEMENTASI
NO. HARI/ JAM TINDAKAN KEPERAWATAN PARAF
DX TGL

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020
 VI. EVALUASI
NO. NO. DX HARI/ JAM EVALUASI PARAF
TGL

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2019/2020