............................................................................................................................................................
............................................................................................................................................................
.
OLEH:
Sri Susan Benedikta Siritoitet
9103017060
FAKULTAS KEPERAWATAN
UNIVERSITAS KATOLIK WIDYA MANDALA SURABAYA
2020
LEMBAR PENGESAHAN
1
LAPORAN
............................................................................................................................................................
............................................................................................................................................................
.......................................................................................................................................................
Dokumentasi asuhan keperawatan ini dibuat untuk memenuhi persyaratan dalam menyelesaikan
mata kuliah Keperawatan Gawat Darurat dan Kritis
Surabaya, ......................................................
Pembimbing Akademik
(......................................................................)
LEMBAR KONSULTASI
NO TANGGAL KEGIATAN TANDA TANGAN
2
LAPORAN PENDAHULUAN
3
DEFINISI
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
4
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
KLASIFIKASI
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
Web of Caution
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
5
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
6
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
GEJALA KLINIS
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
KOMPLIKASI
7
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
PEMERIKSAAN DIAGNOSTIK
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
PENATALAKSANAAN MEDIS
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
8
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
9
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
10
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
ANALISA DATA
NO DATA ETIOLOGI MASALAH
11
NO DATA ETIOLOGI MASALAH
12
RUMUSAN DIAGNOSA KEPERAWATAN
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
13
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
INTERVENSI KEPERAWATAN
NO DIAGNOSA TUJUAN & INTERVENSI RASIONAL
KEPERAWATAN KRITERIA
HASIL
14
15
LAPORAN KASUS ICU
1. IDENTITAS KLIEN
No. Register : …………………………………………………………….
Nama : …………………………………………………………….
Umur : …………………………………………………………….
Jenis kelamin : …………………………………………………………….
Agama : …………………………………………………………….
Alamat : …………………………………………………………….
Suku : …………………………………………………………….
Pekerjaan : …………………………………………………………….
Tanggal/Jam MRS : …………………………………………………………….
Diagnosis Masuk : …………………………………………………………….
Jenis Operasi (bila ada) : …………………………….. Post op hari ke :………….
Keluarga yang dapat dihubungi : …………………………….
2. RIWAYAT PENYAKIT DAHULU
- Pernah dirawat Ya, Kapan …………………….................... Tidak
-Jika Ya, alasan MRS
…………………………………………….…………………………………………….…..
…………………………………………………………………………………………………….
………..
- Penyakit yang pernah di derita
…………………………………..……………………………………………………….…….
………………………………………………………………..……………………………….
…………
4. RIWAYAT ALERGI
Terhadap; Obat, reaksi : ………………………………………….................
Makanan, reaksi : ………………………………………………….....
Plester, reaksi : ………………………………………………….....
Lain-lain : ………………………………………………….....
5. RIWAYAT KETERGANTUNGAN :
Tidak
16
Obat Sebutkan : Sejak :
Napza Sebutkan : Sejak :
Jamu Sebutkan : Sejak :
Rokok Jumlah : Sejak :
Alkohol Jumlah : Sejak :
17
Pengeluaran : Jenis:........................... warna:.....................Jumlah:.......................
Lain- lain
Masalah Keperawatan :
18
7) SpO2:...............%
Keluhan lain (masalah yang dikeluhkan pasien) : ...........................................................................
Masalah Keperawatan :
19
6)IWL: ………….cc/hari
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah keperawatan:
Kompartement sindrome
AVN(Arteri Vein Nervus):
ROM: Aktif Pasif
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):........................................................
Masalah Keperawatan :
20
Hecting: Tidak Ya, Jika Ya: Jenis Benang.............................
2) Palpasi: Turgor Baik Sedang Jelek
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan:
b. Laki-Laki
Penis : bersih, kotor) Testis : (desensus/ undesensus)
Skrotum : .............
Phimosis : .............
Keikutsertaan KB : Tidak / belum pernah Perlu, tapi belum ikut KB
Ya, Metode yang dipakai:
Kondom Alamiah MOP
Condyloma, di : .......................................
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):........................................................
Masalah Keperawatan:
21
DATA PEMENUHAN KEBUTUHAN DASAR
24. NUTRISI
BB ….Kg TB…….. cm IMT………..
Nafsu Makan : Tidak Ada Kurang Berlebihan Normal
Keluhan : Nausea Vomiting Disfagia
Jenis Diet :
Jumlah kalori :
Kebutuhan cairan: ..... cc/24 jam
Pola makan : - Frekuensi : ..........................................................x/hari
- Jenis makanan : .....................................................................
- Makanan yang disukai : .....................................................................
- Makanan yang tidak disukai : ....................................................................
Pola minum : - Jumlah : .................................................... .cc/24jam
- Jenis minuman : ....................................................................
- Minuman yang disukai : .....................................................................
- Minuman yang tidak disukai : .....................................................................
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :
25. ELIMINASI
Buang air kecil:
Lancar Dibantu Mandiri
Frekuensi : ........x/hari Warna : Bau:
Jumlah urine:…….../24jam
Balance cairan:………………….
DATA PSIKOSOSIAL
Komunikasi : Verbal Non verbal
Kemampuan bicara : Lancar Gugup Afasia
22
Bahasa yang dipakai sehari-hari : ....................................................................................................
Pasien tinggal dengan : .....................................................................................................
Orang yang paling dekat : .....................................................................................................
Orang yang membantu di rumah : .....................................................................................................
Apakah pasien mengerti tentang penyakitnya Ya Tidak
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :
DATA SPRITUAL
Melaksanakan ibadah : Ya Tidak
Persepsi terhadap sehat / sakit : .....................................................................................................
Kelainan / keluhan lain : .....................................................................................................
Bantuan yang dibutuhkan : Pastur Pendeta Ustad Pemuka agama lain :
Keyakinan terhadap sakitnya : ......................................................................................................
DATA PENUNJANG
Yang Dibawa Dari Rumah
PEMERIKSAAN DIAGNOSTIK :
Jenis pemeriksaan Tanggal dan jam Hasil pemeriksaan Nilai Kesimpulan
pemeriksaan Normal
Laboratorium darah
Laboratorium urin
Radiologi
23
Pemeriksaan lain
TERAPI MEDIK
Nama obat Dosis Frekuensi Cara pemberian Indikasi Kontraindikasi Efek samping Keterangan
24
Laboratorium urin
Radiologi
Pemeriksaan lain
25
TERAPI MEDIK
Nama obat Dosis Frekuensi Cara pemberian Indikasi Kontraindikasi Efek samping Keterangan
( )
26
ANALISA DATA
NO DATA ETIOLOGI MASALAH
27
NO DATA ETIOLOGI MASALAH
28
RUMUSAN DIAGNOSA KEPERAWATAN (diurutkan berdasarkan prioritas)
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
29
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
INTERVENSI KEPERAWATAN:
NO TUJUAN & INTERVENSI RASIONAL
DX KRITERIA HASIL
30
IMPLEMENTASI KEPERAWATAN
TANGGAL NO IMPLEMENTASI DAN RESPON/ HASIL TT
DAN JAM DX
31
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX
32
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX
33
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX
34
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX
35
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX
36
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX
37
EVALUASI KEPERAWATAN
TANGGAL NO EVALUASI TT
DAN JAM DX
38
TANGGAL NO EVALUASI TT
DAN JAM DX
39
TANGGAL NO EVALUASI TT
DAN JAM DX
TANGGAL NO EVALUASI TT
DAN JAM DX
40
TANGGAL NO EVALUASI TT
DAN JAM DX
41
42