BAGIAN KGD FORMAT PENGKAJIAN KEPERAWATAN KRITIS

STIKes WN
I. Identitas Mahasiswa
Nama : Claudia Natasya Emeralda Wijaya
Nim : 201801010
Kelas : 4A Keperawatan

II. Identitas Klien

Nama : Tn. A Umur : 27 Tahun
No. MR : Jenis Kelamin : Laki-laki
Tanggal : 25 Juli Hari rawat ke : Pertama
Agama : Islam Status : Belum menikah
Alamat rumah : Jln. Suprapto Berat badan : 75 Kg
Alergi : Obat Ciprofloxaxin
Diagnosa Medis :

III. Alasan dirawat di ICU

Klien mengalami kecelakaan lalu lintas, adanya riwayat pingasan 10 menit, muntah
lebih dari 3 kali.

IV. Pengkajian Fisik Dan Pengkajian Umum

Kardiovaskuler Muskuloskeletal
Normal Normal

Dx. Kep: Dx. Kep:

Pernafasan Genitourinaria
Sesaf Nafas Normal

Dx. Kep: GG Pernafasan Dx. Kep:

Neurologis dan Sensori Integumen

Normal Normal

Dx. Kep: Dx. Kep:

Gastrointestinal Endokrin
Normal Normal
 Dx. Kep: Dx. Kep:

Nutrisi Klien Psikososial

Muntah kurang lebih 3 kali

Dx. Kep: Dx. Kep:

Cairan Istirahat Tidur

Cairan infus terpasang RL 20 TTS/menit,
Telah terpasang infus 2 kolf/24 jam

Dx. Kep: Dx. Kep:

V. Monitoring Tiap Jam

6 7 8 9 10 11 12 13 14
H 40
E
M
O
D
39
I
N
A
M
I
K 38

37

36

35
Kesadaran
Irama EKG
Nyeri
CVP

Resp Tipe Vent

PEEP/
CPAP
RR
TV
 Neuro Mata
Ukuran
Reaksi
Kaki
Tangan
GCS
Input Line 1

Line 2

Line 3

Line 4

Enteral

Total
Output NGT
Urine
BAB
Drain
Total

VI. Terapi/Program Medis

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VII. Hasil Uji Diagnostik
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Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan :

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