LAPORAN ASUHAN KEPERAWATAN LENGKAP ICU

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OLEH:
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FAKULTAS KEPERAWATAN
UNIVERSITAS KATOLIK WIDYA MANDALA SURABAYA
2021

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 LEMBAR PENGESAHAN
LAPORAN
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Dokumentasi asuhan keperawatan ini dibuat untuk memenuhi persyaratan dalam menyelesaikan
mata kuliah Keperawatan Gawat Darurat dan Kritis

Surabaya, ......................................................
Preceptor Akademik

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 LEMBAR KONSULTASI
NO TANGGAL KEGIATAN TANDA TANGAN

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 LAPORAN PENDAHULUAN

DIAGNOSA MEDIS: .....................................................................................................

DEFINISI
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ETIOLOGI (Jika ada klasifikasi, berikan penjelasan)

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Web of Caution
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GEJALA KLINIS
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PEMERIKSAAN DIAGNOSTIK
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PENATALAKSANAAN MEDIS
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PENGKAJIAN DATA DASAR KEPERAWATAN

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ANALISA DATA
NO DATA ETIOLOGI MASALAH

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NO DATA ETIOLOGI MASALAH

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RUMUSAN DIAGNOSA KEPERAWATAN
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INTERVENSI KEPERAWATAN
NO DIAGNOSA TUJUAN & INTERVENSI RASIONAL
KEPERAWATAN KRITERIA
HASIL

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NO DIAGNOSA TUJUAN & INTERVENSI RASIONAL
KEPERAWATAN KRITERIA
HASIL

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 LAPORAN KASUS ICU

PENGKAJIAN, Tanggal……………………………., Jam……….

Pilih yang sesuai dengan memberi tanda (√ ) pada ()

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Informasi dari :  Pasien
 Keluarga, Hubungan : Nama :
Orang lain, Hubungan : Nama :

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
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- Penyakit yang pernah di derita
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…………

3. RIWAYAT PENYAKIT KELUARGA

 DM  Hypertensi  Basedow
 Jantung  Epilepsi  asma
 alergi  Kanker  Lain-lain
 Lupus

4. RIWAYAT ALERGI
Terhadap;  Obat, reaksi : ………………………………………….................
 Makanan, reaksi : ………………………………………………….....
 Plester, reaksi : ………………………………………………….....
 Lain-lain : ………………………………………………….....

5. RIWAYAT KETERGANTUNGAN :
 Tidak
 Obat Sebutkan : Sejak :
Napza Sebutkan : Sejak :
Jamu Sebutkan : Sejak :
Rokok Jumlah : Sejak :
Alkohol Jumlah : Sejak :

6. RIWAYAT PENYAKIT SEKARANG …………………………………………………..

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7. KELUHAN UTAMA ………………………………………….....................

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………...………………………………………………………..........................……………..……
Masalah Keperawatan :

8. SAAT MASUK RS :  Berjalan  Dengan Kursi roda  Dengan Brankar

9. ALAT MEDIK YANG DIPAKAI SAAT PENGKAJIAN

 Infus
 Infus Pump  IV Set  Tranfusi Set
Nama cairan:
Jumlah pemberian:............ cc/..... jam
Jumlah tetesan:...................tpm
Lokasi pemasangan:
 Alat bantu nafas
Nasal/masker sederhana :.......... lpm
Masker resevoir :...........lpm
Tracheostomy :
Ventilator :
 Folley Chateter/ Three way Cahteter:
Nomer..................
Isi Balon.................
Warna Urine............
Jumlah....................
 NasoGastricTube
Drain :
Nama :
Lokasi :
Pengeluaran : Jenis:........................... warna:.....................Jumlah:.......................
Lain- lain

Masalah Keperawatan :

10. ALAT BANTU YANG DIGUNAKAN

 Kaca mata  Gigi palsu
 Alat bantu dengar  Lensa kontak
 Walker/ Kruk / kursi roda Protesa
 Pace maker
Masalah Keperawatan :

11. KEADAAN UMUM

 Ringan  Sedang  Berat
Masalah Keperawatan :

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12. PENGKAJIAN NYERI
P (Provocative) :
Q (Quality) :
R(Regio) :
S (Severity Scale) :
T (Time) :
Keluhan lain :
Masalah Keperawatan :

13. TANDA-TANDA VITAL

Suhu : ................... oC
 Aksila  Rektal  Timpani Oral Frontal Lain-lain:.............
Pernafasan : ................... x/mnt  Reguler  Irreguler
Nadi : ................... x/mnt  Reguler  Irreguler
Tekanan darah : ................... mmHg  Berbaring  Duduk  Berdiri
Masalah Keperawatan :

14. SISTEM PERNAFASAN

1) Jalan nafas :  Bersih Obstruksi
2) Inspeksi :
Bentuk dada :  Simetris  Pigeont chest  Barrel chest Funnel chest
Tipe pernafasan :  Perut  Dada  Biot  Kusmaul  Cheyne Stroke
Gerakan otot bantu nafas:  tidak  ya
Jika iya:  Retraksi intercostalis Supraclavicula  Subcostalis
 Suprasternalis sternocleidomastoideus
Ekspansi paru: Simetris,  Asimetris,  Flail chest
Tanda distress nafas : Nafas Cuping Hidung,
Retraksi Intercosta: Ringan Sedang Berat
 Pursed Lips Breathing)
3) Palpasi:  Tumor Krepitasi
4) Auskultasi
Suara nafas :  Vesiculer Area :.................
 Bronkovesikuler Area :.................
Bronchial Area :.................
 Ronchi: + / - Area :..................
 Wheezing : + / - Area :..................
Lain- Lain:............ Area :..................
5) Suara Perkusi :  Sonor  Hipersonor  Redup/Pekak
Lokasi : .....................................................................................................
6) Batuk : Tidak
Ya : Jika Ya: Kering Berdahak
Akumulasi sputum :  Ya  Tidak
Warna : Konsistensi: Jumlah:
7) SpO2:...............%
Keluhan lain (masalah yang dikeluhkan pasien) : ...........................................................................
Masalah Keperawatan :

15. SISTEM JANTUNG DAN PEMBULUH DARAH

1) Inspeksi :
 Clubbing Finger  Distensi Vena Jugularis
 Pucat  Kemerahan
 Sianosis, Jika Ya:  Sentral  Perifer
 Perdarahan pada .................................... Jumlah…….. cc
 Hematoma pada ....................................
 Varises pada .......................................................
Pembesaran kelenjar getah bening:  Ada, Lokasi:............................ Tidak
2) Palpasi :
Akral : Panas Hangat  Kering Merah
 Pucat Basah Dingin

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 Nadi Radialis/ Brakialis : Lemah Kuat Dalam  Dangkal
Nadi Karotis :Lemah  Kuat  Teraba  Tidak Teraba
Capillary Refill / Pengisian Kapiler :  <3 Detik  >3detik
Oedema : Anasarka  Piting : Derajat:..........
AV Shunt  Ada , : Letak:..........................  Tidak
3) Perkusi: Redup/ Pekak
4) Auskultasi :  S1 &S2 Tunggal  Murmur Gallop  Lain- Lain:.....
5) JVP :........ Cm Head Up......0
6) CVP: Letak:....... Nilai:.....cmH2O
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):.............................................................
Masalah Keperawatan :

16. SISTEM PERSYARAFAN

1) Inspeksi
Kesadaran :  Compos Mentis Apatis Dellirium Somnolen Stupor  Coma
Pupil :  Ukuran:  Isokor  Anisokor kanan/kiri
 Myosis  Normal  Midriasis
Reaksi cahaya :  Positif  Negatif (kanan/kiri)

 Konvulsi  Tremor  Kaku kuduk  Tics pada : ...............................  Kesemutan

2) Palpasi:
G.C.S : E:.... V:..... M:.... total GCS:............
 Kernig sign
 Para parese / hemi parese/ tetra parese : ..........................
 Para plegia / hemi plegia/ tetra plegi : .........................
3) Perkusi:
Reflek Normal: Bisep Trisep  Patela, Plantar Achiles
Reflek Patologis: Babinski  Brudzinsky Lain- lain:
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :

17. SISTEM PERKEMIHAN

1)Inspeksi
A)Urethra : Letak  Normal  Hipospadia  Epispadia
B) Kebersihan :  Ya,  Tidak
C) Sekresi :  Fluor Albus  Pus  Darah
D) Utk Laki- Laki: Sircumsition  Unsircumsition
2) Palpasi: Distensi Kandung Kemih :  Ya  Tidak
3)Keluhan:
 Dribbling  Retensi  Inkontinensia  Gross Hematuri  Hesitensi
 Oliguri  Disuria  Anuri Poliuri
4) Irigasi
Nama Cairan :
Jumlah :
Warna :
5)Output/ urine : Jumlah……………Warna…………….. Bau:…………………………..
6)IWL: ………….cc/hari
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah keperawatan:

18. SISTEM PENCERNAAN

1) Inspeksi
Mulut:  Bersih  Candidiasis  Halitosis  Stomatitis Caries  Tumor
Leher : Pembesaran tonsil:  Ada  Tidak
Abdomen:  Striae (Gelap/Putih),  Jejas...................  Hematemesis  Melena
 Muntah, Jika Ya Warna............... Jumlah................. Isi Pengeluaran........
 Menggunakan Kolostomi/ Ileustomi
2) Palpasi:
Abdomen:  Supel  Distended  Lingkar Abdomen:................cm
 Benjolan Di : ...........................................
 Hepatomegali  Splenomegali
Nyeri McBurnei

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 Anus:  Hemmoroid  Atresia Ani  Fissura Ani
3) Perkusi abdomen:  Asites
4) Auskultasi:  Peristaltik/ bising usus : .............x/mnt
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :

19. SISTEM MUSKULOSKELETAL

1) Inspeksi:
 Radang sendi pada : ..................................
 Kaku sendi pada : ..................................  Fraktur pada: ......................................
 Atrofi pada : ..................................  Traksi/ spalk/ gips : ..............................
 Kontraktur  Deformitas
 Pergerakan sendi : bebas/ terbatas
 Kelainan tulang belakang
2) Palpasi:
 Skala Kekuatan Otot :

 Kompartement sindrome
AVN(Arteri Vein Nervus):
ROM: Aktif Pasif
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):........................................................
Masalah Keperawatan :

20. SISTEM INTEGUMEN DAN SELAPUT LENDIR

1) Inspeksi:  Ichterus Petechie Hiperpigmentasi  Malar
 Rash  Acne  Lain- Lain.......
Luka:  Ada, Tidak
Jika Ada:
Bula pada : ............................................................................................................
Laserasi pada : ............................................................................................................
Combutio : Area:.................luas permukaan:...........% Grade.................................
Decubitus pada : Area: ............................ Deraja :...............................................
Ganggren :Area :............................. Derajat:..............
Abses di : ......................................................
Luka post op: area:.............. keadaaan:...............

Gambar Luka: Meliputi Panjang, Lebar, Kedalaman, Keadaan Luka

Hecting: Tidak Ya, Jika Ya: Jenis Benang.............................

2) Palpasi: Turgor  Baik  Sedang  Jelek
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan:

21. SISTEM SENSORI PERSEPSI

Sistem Penglihatan
 Berkunang-Kunang  Kabur  Buta
Sclera :  Icterus  Hiperemi  Putih
Kornea :  Keruh  Bintik-Bintik
Konjungtiva :  Tidak Anemis  Anemis/Pucat  Hiperemis
Oedema Palpebra:  Ya  Tidak
Hordeolum:
Strabismus :  Ya  Tidak
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :

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 Sistem pendengaran
 Tinitus  Berkurang  Nyeri  Tuli (Kanan/Kiri)
 Nyeri Tarikan Daun Telinga  Nyeri Tekan Otorhea ( Cairan/Darah)
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :

22. SISTEM ENDOKRIN

Leher:
Pembesaran kelenjar tiroid :  Ada  Tidak
Parotitis :  Ada  Tidak
Torticollis :  Ada  Tidak
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :

23. SISTEM REPRODUKSI DAN SEKSUALITAS

a. Wanita
Riwayat haid : Siklus haid .......... Haid terakhir …………  Menarche usia...............
Lama Haid ……. Sifat haid : banyak/sedikit ; Gumpal/encer
 Dismenore
 Fluor albus
 Menopouse sejak …………………………..
Paritas : Jumlah kehamilan ……….. Jumlah persalinan …………………….
Keikutsertaan KB :  Tidak / belum pernah  Perlu, tapi belum ikut KB
 Ya. Metode yang dipakai:
 IUD  Kondom  Susuk
 MOW  Pil  Suntik
 Alamiah
 Condyloma, di : .......................................
 Sekresi Vagina : Banyak/ Sedang/ Sedikit  Warna Sekret: ............. Berbau / Tidak
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:

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 : .....................................................................

21
 - 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:………………….

Buang air besar :

 Obstipasi  Konstipasi  Diare  Melena  Lendir Dan Darah
 Dibantu  Mandiri
 Frekuensi :.............x/hari
 Warna : ................ Konsistensi : ................  Jumlah :………..
Penggunaan pencahar: Tidak Ya, Jika Ya :Nama……….. Frekuens………. Dosis…………
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah keperawatan:
26. POLA AKTIVITAS DAN ISTRAHAT
Lama tidur : - Siang : ................... jam
- Malam : ................... jam
Waktu tidur : - Siang pukul : ...................
- Malam pukul : ...................
Kelainan / keluhan lain : ................................................................................................................
Memakai obat tidur :  Tidak  Ya, jika Ya: Nama................ Frekuensi......... Dosis.....
Kegiatan rutin : ................................................................................................................
Latihan fisik :Jenis.................................Durasi.................. Frekuensi................
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan

27. POLA MERAWAT DIRI

Mandi : x/hari  Tergantung  Dibantu  Mandiri
Gosok gigi : x/hari  Tergantung  Dibantu  Mandiri
Cuci rambut : x /minggu  Tergantung  Dibantu  Mandiri
Berpakaian/ Berhias :  Tergantung  Dibantu  Mandiri
Instrumental :  Tergantung  Dibantu  Mandiri
Kuku :  Panjang  Pendek  Bersih  Kotor
Kelainan / keluhan lain (masalah yang dikeluhkan pasien):............................................................
Masalah Keperawatan :

DATA PSIKOSOSIAL
Komunikasi :  Verbal  Non verbal
Kemampuan bicara :  Lancar  Gugup  Afasia
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

22
PEMERIKSAAN DIAGNOSTIK :
Jenis pemeriksaan Tanggal dan jam Hasil pemeriksaan Nilai Kesimpulan
pemeriksaan Normal
Laboratorium darah

Laboratorium urin

Radiologi

Pemeriksaan lain

23
 TERAPI MEDIK
Nama obat Dosis Frekuensi Cara pemberian Indikasi Kontraindikasi Efek samping Keterangan

Saat Di Rumah Sakit

PEMERIKSAAN DIAGNOSTIK :
Jenis pemeriksaan Tanggal dan jam Hasil pemeriksaan Nilai Kesimpulan
pemeriksaan Normal
Laboratorium darah

Laboratorium urin

24
 Radiologi

Pemeriksaan lain

TERAPI MEDIK
Nama obat Dosis Frekuensi Cara pemberian Indikasi Kontraindikasi Efek samping Keterangan

25
 Perawat yang mengkaji

( )

ANALISA DATA

26
NO DATA ETIOLOGI MASALAH

NO DATA ETIOLOGI MASALAH

27
RUMUSAN DIAGNOSA KEPERAWATAN (diurutkan berdasarkan prioritas)

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INTERVENSI KEPERAWATAN:

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NO TUJUAN & INTERVENSI RASIONAL
DX KRITERIA HASIL

30
NO TUJUAN & INTERVENSI RASIONAL
DX KRITERIA HASIL

31
IMPLEMENTASI KEPERAWATAN
TANGGAL NO IMPLEMENTASI DAN RESPON/ HASIL TT
DAN JAM DX

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TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT

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DAN JAM DX

TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT

DAN JAM DX

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TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT

35
DAN JAM DX

TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT

DAN JAM DX

36
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX

37
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX

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TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX

39
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX

40
TANGGAL NO IMPLEMENTASI DAN RESPON HASIL TT
DAN JAM DX

41
EVALUASI KEPERAWATAN
TANGGAL NO EVALUASI TT

42
DAN JAM DX

TANGGAL NO EVALUASI TT
DAN JAM DX

43
TANGGAL NO EVALUASI TT
DAN JAM DX

44
TANGGAL NO EVALUASI TT
DAN JAM DX

45
TANGGAL NO EVALUASI TT
DAN JAM DX

46
LAPORAN ASUHAN KEPERAWATAN LENGKAP IGD

47
............................................................................................................................................................
.......................................................................................................................................................

OLEH:
...................................................
....................................................

FAKULTAS KEPERAWATAN
UNIVERSITAS KATOLIK WIDYA MANDALA SURABAYA
2021
LEMBAR PENGESAHAN

48
 LAPORAN
............................................................................................................................................................
............................................................................................................................................................
.......................................................................................................................................................

Dokumentasi asuhan keperawatan ini dibuat untuk memenuhi persyaratan dalam menyelesaikan
mata kuliah Keperawatan Gawat Darurat dan Kritis

Surabaya, ......................................................
Preceptor Akademik

(......................................................................)

LEMBAR KONSULTASI
NO TANGGAL KEGIATAN TANDA TANGAN

49
LAPORAN PENDAHULUAN

50
DIAGNOSA MEDIS: .....................................................................................................

DEFINISI
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ETIOLOGI (Jika ada klasifikasi, berikan penjelasan)

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Web of Caution
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GEJALA KLINIS
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PEMERIKSAAN DIAGNOSTIK
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PENATALAKSANAAN MEDIS
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54
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PENGKAJIAN DATA DASAR KEPERAWATAN

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ANALISA DATA
NO DATA ETIOLOGI MASALAH

56
NO DATA ETIOLOGI MASALAH

57
RUMUSAN DIAGNOSA KEPERAWATAN
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ASUHAN KEPERAWATAN
NO DIAGNOSA TUJUAN & INTERVENSI RASIONAL
KEPERAWATAN KRITERIA
HASIL

59
NO DIAGNOSA TUJUAN & INTERVENSI RASIONAL
KEPERAWATAN KRITERIA
HASIL

60
 LAPORAN KASUS IGD

Tanggal : ……………………………………………. Jam datang: ………………..

61
Nama :......................................................................................................................
Jenis Kelamin :......................................................................................................................
Umur :......................................................................................................................
Agama :......................................................................................................................
Pendidikan :......................................................................................................................
Pekerjaan :......................................................................................................................
Alamat :......................................................................................................................
Dignosa Medis :......................................................................................................................

SOAPIE JAM ASUHAN KEPERAWATAN PERAWAT

S

62
I

63
E

Perawat Pelaksana

( )

64