A. IDENTITAS KLIEN
1. Nama inisial klien : .........................................................
2. Umur : .........................................................
3. Alamat : .........................................................
4. Pekerjaan : .........................................................
5. Agama : .........................................................
6. Tanggal masuk RS : .........................................................
7. Nomor Rekam Medis : .........................................................
8. Diagnosa Medis : .........................................................
B. PENGKAJIAN UMUM
1. Keluhan utama klien masuk ICU:
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2. Riwayat Penyakit Sekarang (yi sejak klien mengeluhkan gejala pertama ketika di rumah sampai
klien dibawa ke Rumah Sakit karena keluhan tersebut tidak berkurang/malah bertambah parah):
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3. Riwayat Penyakit Dahulu:
a. Apakah klien pernah dirawat di Rumah Sakit : Ya/tidak. Jika ya, dengan diagnose medis
apa……………….dan berapa hari dirawat…………………………………………………..
4. Riwayat Sosial:
a. Apakah klien merokok : Ya/tidak. Jika ya, berapa bungkus perhari………
b. Apakah klien mengkonsumsi analgetik : Ya/tidak. Jika ya, sebutkan merknya……………
5. Riwayat Penyakit Keluarga:
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C. PENGKAJIAN 13 DOMAIN NANDA
1. HEALTH PROMOTION (Meliputi Kesadaran Kesehatan dan Manajemen Kesehatan) :
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2. NUTRITION (Meliputi perbandingan antara intake sebelum dan sesudah sakit) :
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3. ELIMINATION (Meliputi frekuensi BAK/BAB sebelum dan sesudah sakit, jelaskan
karakteristik BAB dan BAK tersebut, ada mual dan muntah tidak)
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4. ACTIVITY/REST(Meliputi jam tidur sebelum dan sesudah sakit, adakah gangguan tidur):
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5. PERCEPTION/COGNITION (Meliputi cara pandang klien tentang penyakitnya, apakah klien
memiliki pemahaman yang cukup terkait penyakit yang diderita) :
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6. SELF PERCEPTION (Meliputi apakah klien merasa cemas/takut tentang keadaannya sekarang):
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7. ROLE RELATIONSHIP (Meliputi hubungan klien dengan perawat/dokter yang merawat,
hubungan dengan suami/anggota keluarga lainnya) :
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8. SEXUALITY (Meliputi aktivitas seksual selama sakit, apakah klien pernah mengalami masalah
seksual sebelum sakit) :
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9. COPING/STRESS TOLERANCE (Meliputi bagaimana cara klien mengatasi stressor saat sakit
sekarang, jika penyakit tidak dapat disembuhkan atau bertambah parah maka apa tindakan
klien):
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10. LIFE PRINCIPLES (Meliputi apakah klien tetap menjalankan sholat/ibadah yang lain selama
proses perawatan, apakah klien mengikuti kegiatan keagamaan sebelum masuk perawatan, apa
prinsip hidup yang dimiliki klien) :
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11. SAFETY/PROTECTION (Meliputi apakah klien menggunakan alat bantu jalan, apakah
pengaman di samping tempat tidur berfungsi dengan baik, apakah tersedia selimut untuk
mengatasi cuaca dingin) :
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12. COMFORT (Meliputi apakah klien merasa nyaman dengan proses perawatan sekarang,
bagaimana penampilan psikologis klien seperti tenang, bingung) :
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13. GROWTH/DEVELOPMENT (Meliputi berapakah kenaikan berat badan klien selama perawatan
sekarang):
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TANGGAL JENIS
HASIL PEMERIKSAAN INTERPRETASI
DAN JAM PEMERIKSAAN
G. TERAPI YANG DIBERIKAN
TANGGAL
JENIS TERAPI RUTE TERAPI DOSIS INDIKASI
DAN JAM
Tanggal Data
No Etiologi Problem Prioritas
& Jam (Subjektif & Objektif)
RENCANA KEPERAWATAN