FORMAT PENGKAJIAN ASKEP DI RUANG ICCU

No. RM : .............................................
Hari, tanggal : .............................................
Ruang :.............................................

I. DATA UMUM
1. Identitas klien
Nama : ……………….
Umur : ……………….
Tempat/Tgl lahir : ……………….
Jenis Kelamin : ……………….
Agama : ……………….
Suku : ……………….
Pendidikan : ……………….
Dx. Medis : ……………….
Alamat : ……...............
Tanggal MRS : ……………….
Ruangan : …………........
Gol. Darah : ……………….
Sumber Info. : ……………….

2. Identitas penanggung jawab

Hub. dengan pasien : …………….........
Umur : ………………......
Nama : …………….........
Pendidikan :……………..........
Pekerjaan : ………………......
Alamat :...........................
Telp : …………….........

II. RIWAYAT KESEHATAN SAAT INI

1. Keluhan Utama : ……………………………………………..........
......................................................................................................................

2. Alasan masuk rumah sakit : .........................................................................

......................................................................................................................

3. Riwayat Penyakit: ……………………………………………...................

......................................................................................................................

III. RIWAYAT KESEHATAN DAHULU

1. Penyakit yang pernah dialami: ....................................................................
2. Penyebab : ………………………………....................
Riwayat Perawatan : …………………………………................
Riwayat Operasi : …………………………………………...
Riwayat Pengobatan : ………………………………....................
 3. Kecelakaan yang pernah dialami : …………………………………….....
4. Riwayat Alergi : ……………………………………….......

IV. RIWAYAT PSIKOLOGI DAN SPIRITUAL

1. Riwayat Psikologi
a. Tempat tinggal : ……………………………………………........
b. Lingkungan rumah : …………………………………………............
c. Hubungan antar
anggota keluarga : …………………………………………….........
d. Pengasuh anak : …………………………………………….........
2. Riwayat Spiritual
a. Support sistem : ……………………………………………........
b. Kegiatan keagamaan : ………………………………………………..
3. Riwayat Hospitalisasi : ………………………………………………….

V. POLA FUNGSI KESEHATAN (11 POLA FUNGSIONAL GORDON)

1) Pemeliharaan dan persepsi terhadap kesehatan
Jelaskan :........................................................................................................
...
2) Pola Nutrisi/metabolic
Jelaskan :........................................................................................................
...
3) Pola eliminasi
Jelaskan :........................................................................................................
...
4) Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain
dan alat, 4: tergantung total.

Jelaskan :....................................................................................................
.......

Okigenasi:

Jelaskan :....................................................................................................
.......
5) Pola tidur dan istirahat
 Jelaskan :........................................................................................................
...
6) Pola kognitif-perseptual
Jelaskan :........................................................................................................
...
7) Pola persepsi diri/konsep diri
Jelaskan :........................................................................................................
...
8) Pola seksual dan reproduksi
Jelaskan :........................................................................................................
...
9) Pola peran-hubungan
Jelaskan :........................................................................................................
...
10) Pola manajemen koping stress
Jelaskan :........................................................................................................
...
11) Pola keyakinan-nilai
Jelaskan :........................................................................................................
...

VI. PEMERIKSAAN FISIK

Hari ……………………, Tanggal ………………., Jam ………......
1. Keadaan Umum
a. Kesadaran : …………………………………...
b. Penampilan dihubungkan
dengan usia : ………………………………......
c. Ekspresi wajah : …………………………………...
d. Kebersihan secara umum : …………………………………...
e. Tanda-Tanda Vital : ………………………………......

2. Head to toe
1) Kulit/integument
Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

2) Kepala & Rambut

Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..
3) Kuku
Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

4) Mata/penglihatan
Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

5) Hidung/penciuman
Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

6) Telinga/pendengaran
Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

7) Mulut & Gigi

Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

8) Leher
Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

9) Dada/Thorak
Inspeksi :
……………………………………………………………….
 Palpasi :
………………………………………………………………..

Perkusi :
……………………………………………………………….

Auskultasi :
………………………………………………………………..

10) Jantung
Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..

Perkusi :
……………………………………………………………….

Auskultasi :
………………………………………………………………..

11) Abdomen
Inspeksi :
……………………………………………………………….

Auskultasi :
………………………………………………………………..

Palpasi :
……………………………………………………………….

Perkusi :
………………………………………………………………..

12) Perineum & Genitalia

Inspeksi : ..............................................................................................

13) Extremitas atas & bawah

Inspeksi :
……………………………………………………………….

Palpasi :
………………………………………………………………..
3. Pengkajian Data Fokus (Pengkajian Sistem)
a. Sistem Respiratori (Breathing)

Jelaskan : ..............................................................................................

b. Sistem Kardiovaskular (Blood)

Jelaskan: ...............................................................................................
.

c. Sistem Gastrointestinal (Bowel)

Jelaskan: ...............................................................................................
.

d. Sistem Urinaria (Bladder)

Jelaskan: ...............................................................................................
.

e. Sistem Muskuloskeletal (Bone)

Jelaskan: ...............................................................................................
...

f. Sistem Neurologi (Behavior/Brain)

Jelaskan: ...............................................................................................
..

4. Pemeriksaan Diagnostik : pemeriksaan foto rontgen dan

laboratorium

5. Penatalaksanaan Medis
 Singaraja,.................................2022
Yang
Mengkaji,

....................................
......................
NIM.

ANALISA DATA

Nama :.................................. No. RM :..................................................

Umur :.................................. Dx Medis :...................................................
 Ruang rawat :.................................. Alamat :...................................................
NO DATA FOKUS ETIOLOGI PROBLEM

S:

O:
DIAGNOSA KEPERAWATAN
1. .............................................................................................................................
.............................................................................................................................
.......................
2. .............................................................................................................................
.............................................................................................................................
.......................
3. .............................................................................................................................
.............................................................................................................................
.......................
4. .............................................................................................................................
.............................................................................................................................
........................
5. ...........................................................................................................................
…………….........................................................................................................
...............

RENCANA TINDAKAN KEPERAWATAN

Inisial Klien :........................................

Ruangan :........................................
No.RM :........................................

Hari Rencana Tindakan Keperawatan

Diagnosa
, tgl, Paraf
Keperawatan Tujuan Intervensi Rasional
jam
 IMPLEMENTASI ASUHAN KEPERAWATAN

Inisial Klien :................................................

Ruangan : ...............................................
No. R.M :................................................

Hari,
Diagnosa Implementasi Respon
tgl, Paraf
Keperawatan Keperawatan (EvaluasiFormatif)
jam
EVALUASI SUMATIF/
 CATATAN PERKEMBANGAN

Inisial Klien : ............................................

Ruangan :.............................................
No. R.M :.............................................
Hari, tgl, Diagnosa Evaluasi Sumatif
Paraf
jam keperawatan (SOAP)
 Singaraja,.................................2022
Yang
Mengkaji,

....................................
......................
NIM.
 FORMAT ANALISA TINDAKAN KEPERAWATAN

Nama :........................................................................
NIM :........................................................................
Jenis Tindakan :........................................................................

1. Identitaspasien
Nama :........................................................................
Umur :........................................................................
JenisKelamin :........................................................................
Pekerjaan :........................................................................
Agama :........................................................................
Tanggalmasuk :........................................................................
Alasanmasuk :........................................................................
Dx Medis :........................................................................

2. TahapPersiapan
Persiapanpasien :.....................................................................................
......................................................................................
......................................................................................
......................................................................................
......................................................................................
Persiapanlingku :.....................................................................................
ngan ......................................................................................
......................................................................................
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Persiapan Alat :.....................................................................................
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………………………………………………………
 ……………………………………………………….

3. TahapPelaksanaan

No Pelaksanaan

4. Tahap Akhir

Terminasi :.........................................................................................
 ..........................................................................................
..........................................................................................
Evaluasi :.........................................................................................
..........................................................................................
..........................................................................................
Dokumentasi :.........................................................................................
..........................................................................................
..........................................................................................

5. Analisa Materi Tindakan

Pengertian Tindakan :..............................................................................
...............................................................................
...............................................................................
...............................................................................
...............................................................................
...............................................................................
Tujuan Tindakan :..............................................................................
...............................................................................
...............................................................................
...............................................................................
...............................................................................
...............................................................................
...............................................................................
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6. Evaluasi Hasil Tindakan

Hasil Tindakan :.......................................................................................

........................................................................................
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7. Evaluasi Diri

EvalauasiDiri :.......................................................................................
........................................................................................
........................................................................................
........................................................................................
........................................................................................
........................................................................................

Singaraja,..........................2022
Mahasiswa,

..................................................
NIM.......................................