Form Pengkajian ICU

I. Identitas Mahasiswa
Nama : ............................................. Tgl Praktek : ............................................
NIM : .............................................
II. Identitas Klien
Nama : ............................................., Umur : ..............................................
No MR : ............................................., Jenis Kelamin : …………….……………….
Tanggal : ............................................., Hari rawat ke : ..............................................
Agama : ............................................., Status : ..............................................
Alergi : ............................................., BB : ..............................................
Alamat rumah : ..............................................................................................................................
Diagnosa medis : .............................................................................................................................

III. Alasan di rawat di ICCU/ICU

IV. Riwayat Penyakit

V. Pengkajian fisik dan pengkajian umum

Pernapasan Kardiovaskuler

Dx Kep: Dx Kep:

Neurologis
Muskuloskeletal
dan sensori

Dx Kep: Dx Kep:

Gastrointestinal Endokrin

Dx Kep: Dx Kep:

Integumen Nutrisi
 Dx Kep: Dx Kep:

Genitourinaria Lain-lain

Dx Kep: Dx Kep:

VI. Terapi/Program medis

Nama obat dosis Rute dan waktu Efek samping
pemberian

VII. Hasil pemeriksaan diagnostik

VIII. Monitoring tiap jam

H 250
E Temp
M X
O
D Biru
I 200
N MAP
A
M
I Hijau
K 150
BP

Hitam
100

HR

50
Merah

Kesadaran
Irama EKG
Nyeri
CVP
SaO2/SPO2
Res Tipe Vent
Pir PEEP/CPAP
a RR
si TV
FiO2
N Mata
E Ukuran
U Pupil
R Reaksi
O Kaki
Tangan
GCS
M Line 1
A
S Line 2
U
K Line 3

Line 4

Enteral

Total
K NGT
E Urine
L BAB
U Drain
A Total
R