ASUHAN KEPERAWATAN KRITIS PADA TN.

M
DENGAN NSTEMI
DI INTENSIF CARE UNIT RSUP Dr. KARIADI SEMARANG
Disusun untuk memenuhi tugas Keperawatan Gawat Darurat dan Kritis
Pembimbing Akademik : ........................................................
Pembimbing Klinik : ........................................................

Disusun oleh :

PROGRAM PENDIDIKAN PROFESI NERS ANGKATAN XXXIV

DEPARTEMEN KEPERAWATAN FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
2019
 BAB II
ASUHAN KEPERAWATAN KRITIS

I. Pengkajian
Tanggal Pengkajian : ......................................................................
Tanggal Masuk Ruangan : ......................................................................
Ruang : ......................................................................

A. Identitas
1. Identitas Klien
Nama : ......................................................................
No. Rekam Medis : ......................................................................
Umur : ......................................................................
Jenis Kelamin : ......................................................................
Agama : ......................................................................
Pekerjaan : ......................................................................
Suku : ......................................................................
Bahasa : ......................................................................
Alamat : ......................................................................

2. Identitas Penanggung Jawab

Nama : ......................................................................
Umur : ......................................................................
Pekerjaan : ......................................................................
Suku : ......................................................................
Hubungan dg Klien : ......................................................................
Bahasa : ......................................................................
Alamat : ......................................................................

B. PENGKAJIAN PRIMER:
1. Airway (jalan nafas)
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2. Breathing
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3. Circulation
a. Vital sign:
1) Tekanan darah :
mm/Hg
2) Nadi :
kali/menit
3) Suhu :
0
C
4) Respirasi : kali/menit
b. Capilarry refill : detik
c. Akral :
d. MAP :
4. Disability
a. Keadaan umum : ..................................................................................
b. GCS : E ..... M...... V ......
c. Pupil : ..................................................................................
d. Gangguan motorik : ..................................................................................
e. Gangguan sensorik : ..................................................................................

5. Eksposure

C. Pengkajian Sekunder
1. Anamnesis (SAMPLE)
S (Signs and Symptoms)
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A (Allergies)
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M (Medications)
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P (Pertinent Medical History)
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L (Last Meal)
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E (Events)
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2. Pemeriksaan Fisik
a. Kepala
Inspeksi :
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Palpasi :
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b. Telinga
Inspeksi :
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Palpasi :
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c. Mata
Inspeksi :
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Palpasi :
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d. Mulut dan Gigi
Inspeksi :
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Palpasi :
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e. Hidung
Inspeksi :
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Palpasi :
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f. Leher
Inspeksi :
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Palpasi :
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g. Dada dan Paru
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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h. Jantung
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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i. Abdomen
Inspeksi :
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 Auskultasi :
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Palpasi :
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Perkusi :
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j. Genetalia
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k. Esktremitas Atas
Dextra
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Sinistra
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l. Ekstremitas Bawah
Dextra
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Sinistra
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3. Pengkajian Fungsional
a. Nutrisi dan Cairan
Jenis Sebelum Sakit Saat Sakit
 Makan Frekuensi
Porsi
Jenis
Minum Porsi
Jenis

Balance Cairan
Intake Output
Infus : BAK :
BAB :
IWL :
Minum :
Makan : Jumlah:
Jumlah :

*BC/7 jam = Intake – Output

b. Eliminasi
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c. Termoregulasi
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d. Aktivitas dan Latihan

....
ADL 0 1 2 3 4
Mandi
Berpakaian
Eliminasi
Makan dan Minum
Mobilisasi
Ambulasi
Total Skor
Keterangan 1 : Mandiri
2 : Dibantu Sebagian
3 : Perlu Bantuan orang lain
4 : Perlu bantuan orang lain dan alat
 Indeks Katz
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e. Rasa Aman dan Nyaman
Pengkajian nyeri (CPOT)
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D. Pemeriksaan Penunjang
a. Pemeriksaan Radiologi
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b. Pemeriksaan EKG
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c. Pemeriksaan Laboratorium
Tanggal :
Jenis Pemeriksaan Hasil Satuan Nilai Normal Interpretasi
Tanggal :
Jenis Pemeriksaan Hasil Satuan Nilai Normal Interpretasi
 E. Terapi Medis
Nama Obat Dosis Rute Indikasi Kontraindikasi Efek Samping
 II. Analisa Data
Hari, No Diagnosa
Data Masalah Etiologi
tanggal Dx Keperawatan
 III. Rencana Keperawatan
Hari, No Tujuan dan Kriteria Hasil Intervensi TTD
tanggal Dx
 IV. Implementasi
Hari, No Jam Impelmentasi Respon TTD
tanggal Dx
 V. Evaluasi
Hari, tanggal No Evaluasi TTD
Dx
 BAB III
PEMBAHASAN

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