ASUHAN KEPERAWATAN KRITIS PADA PASIEN Nn.

W DENGAN
MENINGOENCHEPALITIS

DI RUANG ICU RST DR. SOEDJONO MAGELANG

Oleh

HANA PUTRI SETYANI

20101440118032

SEKOLAH TINGGI KESEHATAN KESDAM IV/ DIPONEGORO

PRODI D III KEPERAWATAN

TA 2020/2021
 FORMAT PENGKAJIAN
ASUHAN KEPERAWATAN KRITIS ( ICU/HCU)

ASUHAN KEPERAWATAN PADA Nn. W

DENGAN MENINGOENCHEPALITIS DI RUANG ICU
RST DR. SOEDJONO MAGELANG

I. PENGKAJIAN
Pengkajian dilakukan pada tanggal : 23 Febuari 2021 Jam : 10.00
A. Identitas
1. Identitas Klien : Nn. W
Umur : 25 tahun
Jenis kelamin : Perempuan
Suku /Bangsa : Jawa
Status Perkawinan : Belum Menikah
Agama : Islam
Pendidikan : S1
Alamat : Tegalrejo
Tanggal masuk : 22 Febuari 2021
No Register :
Diagnosa Medis : Meningoenchepalitis
2. Identitas Penanggung Jawab
Nama :
Umur :
Alamat :
Pendidikan :
Pekerjaan :
Hubungan dengan Klien:

B. Keluhan Utama
Klien datang dengan penurunan kesadaran

C. Pengkajian Primer
1. Airway
Jalan nafas terbuka, tidak ada benda asing di rongga mulut , tidak ada suara
tambahan
2. Breathing
Nafas cepat , RR 34x/mnt , Spo2 84%
3. Circulation
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4. Disability
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5. Exposure
Tidak ada jejas diseluruh tubuh
D. Pengkajian Sekunder
1. Riwayat Keperawatan / Kesehatan
a. Riwayat Kesehatan / Keperawatan Sekarang
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b. Riwayat Kesehatan / Keperawatan Dahulu

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c. Riwayat Kesehatan / Keluarga

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2. Pemeriksaan Fisik
a. Keadaan Umum
Kesadaran Somnolen (E2 M2 V3)
b. Pemriksaan Tanda – tanda vital
TD :
HR :
RR :
SpO2:
Suhu:
c. Pemeriksaan Head to toe
1) Pemeriksaan Kepala dan leher
Kepala
Insperksi/ palpasi : Bentuk kepala bulat
Keluhan : Nyeri kepala
Rambut : Rambut hitam bergelombang

Mata
Fungsi penglihatan : Baik
Ukuran pupil : Isokor
Konjungtiva : Anemis
Keluhan : Tidak ada keluhan

Telinga
Fungsi pendengaran : Baik
Keluhan : Tidak ada keluhan

Hidung
Inspeksi : Terpasang selang NGT
Palpasi : Tidak ada nyeri tekan
Keluhan : Tidak ada keluhan

Mulut
Keadaan bibiir : Kering
Kebersihan gigi mulut : Bersih
Pemasangan Opa/et : Tidak

Leher
 Insperksi : Simetris
Palpasi : Tidak ada pembesaran tyroid

d. Pemeriksaan Dada
Jantung
Inspeksi : Ictus cordis tak tampak
Palpasi : Redup
Perkusi : Ictus cordis teraba di IC V mid clavicula
Auskultasi : Bunyi jantung I dan II murni

Paru – Paru
Inspeksi : Dada simetris
Palpasi : Taktil framiitus kanan sama dengan kiri
Perkusi : Sonor
Auskultasi : Tidak ada suara tambahan

Abdomen
Inspeksi : Datar
Auskultasi : Peristaltik usus 8x/mnt
Palpasi : Tidak teraba masa dan tidak ada nyeri
Perkusi : Tympani

e. Genetalia
Terpasang DC

f. Pemeriksaan Anggota Gerak

4 4

4 4

g. Pemeriksaan Kulit dan Kelenjar Getah Bening

Kulit : Lembab

Kelenjar getah bening : Tidak ada benjolan

3. Kebutuhan Fisiologis
a. Pola Nutrisi dan Metabolisme
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b. Pola Eliminasi
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c. Pola Istirahat Tidur

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E. Pemeriksaan Penunjang
a. Laboratorium
 b. Radiologi

c. Terapi

II. ANALISA DATA

N TANGGAL /
DATA FOKUS ETIOLOGI MASALAH TTD
O JAM
III. RENCANA KEPERAWATAN

TANGGAL/ DP TUJUAN DAN INTERVENSI TTD

 JAM KRITERIA HASIL

IV. IMPLEMENTASI
 TANGGAL/JA
DP IMPLEMENTASI RESPON TTD
M

V. EVALUASI
TANGGAL/JA
DP EVALUASI TTD
M