ASUHAN KEPERAWATAN KEGAWATDARURATAN

PADA .............. DENGAN DIAGNOSA MEDIS...............................

................................................................................................
DI RUANG ICU RSUP dr. SOERADJI TIRTONEGORO
KLATEN

Disusun Oleh :

DONATUS DATO
NIM: PN.18.0146

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN WIRA HUSADA
YOGYAKARTA
2019
 HALAMAN PENGESAHAN

ASUHAN KEPERAWATAN KEGAWATDARURATAN

PADA .............. DENGAN DIAGNOSA MEDIS...............................
................................................................................................
DI RUANG ICU RSUP dr. SOERADJI TIRTONEGORO
KLATEN

Asuhan keperawatan ini telah dibaca dan diperiksa pada

Hari/ tanggal: .........................................

Pembimbing Klinik Mahasiswa

(............................................... ) (Donatus Dato)

Mengetahui,
Pembimbing Akademik

(.............................................................................)
 ASUHAN KEPERAWATAN KEGAWATDARURATAN
PADA .............. DENGAN DIAGNOSA MEDIS...............................
................................................................................................
DI RUANG ICU RSUP dr. SOERADJI TIRTONEGORO
KLATEN

Hari / Tgl Pengkajian : Jam : WIB

Nama Mahasiswa : Donatus Dato
NIM : PN.18.0146
Rumah Sakit / Ruang : RSUP dr. Soeradji Tirtonegoro Klaten / ICU
Sumber Data : Pasien, Keluarga, RM.
Metode Pengumpulan Data : Wawancara, Observasi, Pemeriksaan Fisik.

A. IDENTITAS
1. Klien
Nama : ................................................................................
Tempat, tgl lahir : ................................................................................
Umur : ................................................................................
Jenis Kelamin : ................................................................................
Agama : ................................................................................
Status Perkawinan : ................................................................................
Pendidikan : ................................................................................
Pekerjaan : ................................................................................
Suku / Bangsa : ................................................................................
Alamat : ................................................................................
No RM : ................................................................................
Tanggal Masuk RS : ................................................................................
Dx Medis :.................................................................................

2. Penanggung Jawab
Nama : ................................................................................
Umur : ................................................................................
Pendidikan : ................................................................................
Pekerjaan : ................................................................................
Alamat : ................................................................................
Hubungan dengan pasien: ................................................................................
B. RIWAYAT KESEHATAN
1. Riwayat Kesehatan Klien
a) Keluhan Utama:
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b) Riwayat Penyakit Sekarang :
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c) Riwayat Penyakit Dahulu :
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 2. Riwayat KesehatanKeluarga :
a) Genogram

b) Riwayat Kesehatan Keluarga

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C. POLA KEBIASAAN KLIEN

1. Pola Persepsi dan Pemeliharaan Kesehatan
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2. Pola Nutrisi dan Metabolik
Sebelum Sakit
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 Selama Sakit
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3. Pola Eliminasi
Sebelum Sakit
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Selama Sakit
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4. Pola Aktivitas dan Latihan
a. Sebelum Sakit
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b. Selama Sakit
1) Penilaian kemampuan klien dalam beraktivitas selama sakit (beri
tanda √)
Kemampuan perawatan diri 0 1 2 3 4
Makan minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi ROM
0 = Mandiri
1 = Dengan Alat Bantu
2 = Dibantu orang lain
3 = Dengan alat bantu dan dibantu orang lain
 4 = Ketergantungan total
Kesimpulan :
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5. Pola Tidur dan Istirahat
Sebelum Sakit
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Selama Sakit
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6. Sensori, Persepsi dan Kognitif
Sebelum Sakit
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Selama Sakit
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7. Konsep Diri
a) Identitas Diri
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 b) Harga Diri
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c) Peran Diri
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8. Pola Reproduksi dan Seksual
Sebelum Sakit
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Selama Sakit
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9. Pola Peran dan Hubungan
Sebelum Sakit
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Selama Sakit
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10. Pola Manajemen Koping Stress
Sebelum Sakit
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Selama Sakit
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11. Sistem Nilai dan Keyakinan
Sebelum Sakit
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Selama Sakit
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D. PEMERIKSAAN FISIK
1. Keadaan Umum :
a) Tingkat Kesadaran : GCS : E= V= M=
b) Antropometri :
TB :
BB :
Penilaian Status Gizi :
c) Tanda Vital
BP :
HR :
T :
RR :
SpO2 :
2. Pemeriksaan Fisik Sistemik
a) Kepala
Bentuk dan kulit kepala
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....................................................................................................................
Rambut
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Kesan Wajah
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b) Mata, Telinga, Hidung
Mata
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....................................................................................................................
Telinga
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....................................................................................................................
Hidung
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c) Mulut
Bibir
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Gigi
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....................................................................................................................
Lidah
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....................................................................................................................
Tenggorokan

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d) Leher
Inspeksi
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Palpasi
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e) Dada/thoraks
Jantung
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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Paru-Paru
Inspeksi
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Palpasi
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Perkusi
 ....................................................................................................................
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Auskultasi
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f) Payudara
Inspeksi
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Palpasi
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g) Abdomen
Inspeksi
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Auskultasi
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Perkusi
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Palpasi
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h) Genetalia
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i) Ekstremitas
Atas
Inspeksi
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 Palpasi
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Bawah
Inspeksi
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Palpasi
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j) Kulit
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E. PEMERIKSAAN PENUNJANG
1) Laboratorium
Hari/
tanggal/ Jenis Pemeriksaan Hasil Nilai Normal Interpretasi
jam

2) Radiologi
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3) EEG, USG, MRI, EKG
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4) Scanning
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F. TERAPI MEDIS YANG DIDAPAT
No Nama Obat Dosis Indikasi Rute
G. ANALISA DATA
Data Problem Etiologi
H. DIAGNOSA KEPERAWATAN (berdasarkan prioritas masalah)

1. ..........................................................................................................................
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2. ..........................................................................................................................
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3. ..........................................................................................................................
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4. ..........................................................................................................................
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 RENCANA ASUHAN KEPERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

Hari/tgl
Dx. Keperawatan Tujuan (NOC) Intervensi (NIC)
jam

Indikator A T
 CATATAN PERKEMBANGAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

No. Hari/ Evaluasi

Implementasi TTD
Dx. Tgl Proses Hasil
S:

O:

A:
Indikator A T C

P: