ASUHAN KEPERAWATAN

PADA PASIEN.................................................................
DENGAN DIAGNOSA MEDIS...............................
DI RUANG..............................................

DEPARTEMEN

KEPERAWATAN KRITIS

Disusun Oleh:

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

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA
JOMBANG
2018/2019

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
 PRAKTIK PROFESI NERS
PROGRAM STUDI PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN
INSAN CENDEKIA MEDIKA JOMBANG
Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886
Email: stikes.icme@yahoo.com

Asuhan Keperawatan pada pasien.................................

Dengan Diagnosa Medis..................................
di Ruang...........................................

I. PENGKAJIAN
A. Tanggal Masuk :.......................................................................................................................
B. Jam masuk :.......................................................................................................................
C. Tanggal Pengkajian :.......................................................................................................................
D. Jam Pengkajian :.......................................................................................................................
E. No.RM :.......................................................................................................................
F. Identitas
1. Identitas pasien
a. Nama :.............................................................................................................
b. Umur :.............................................................................................................
c. Jenis kelamin :.............................................................................................................
d. Agama :.............................................................................................................
e. Pendidikan :.............................................................................................................
f. Pekerjaan :.............................................................................................................
g. Alamat :.............................................................................................................
h. Status Pernikahan :.............................................................................................................
2. Penanggung Jawab Pasien
a. Nama :.............................................................................................................
b. Umur :.............................................................................................................
c. Jenis kelamin :.............................................................................................................
d. Agama :.............................................................................................................
e. Pendidikan :.............................................................................................................
f. Pekerjaan :.............................................................................................................
g. Alamat :.............................................................................................................
h. Hub. Dengan PX :.............................................................................................................

G. Pengkajian
1. Primary Survey
a. Airway
1) Posisi kepala :......................................................................................................................
Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
 2) Secret/sputum :....................................................................................................................
3) Reflek batuk :......................................................................................................................
4) Lidah jatuh :........................................................................................................................
5) Benda asing :.......................................................................................................................
6) Gigi :....................................................................................................................................
7) Epistaksis :...........................................................................................................................
8) Data lain :............................................................................................................................
b. Breathing
1) Frekuensi nafas :..................................................................................................................
2) Irama nafas :........................................................................................................................
3) Suara nafas :........................................................................................................................
4) Kedalaman nafas :...............................................................................................................
5) Pola nafas :..........................................................................................................................
6) Jenis pernafasan :................................................................................................................
7) Suara tambahan :.................................................................................................................
8) Ekspansi dada :....................................................................................................................
9) Batuk :.................................................................................................................................
10) Data lain :............................................................................................................................
c. Circulation
1) Tekananan darah :...............................................................................................................
2) Bunyi jantung :....................................................................................................................
3) Akral :..................................................................................................................................
4) Sianosis :.............................................................................................................................
5) CRT :...................................................................................................................................
6) Suhu :...................................................................................................................................
7) Odem :.................................................................................................................................
8) Tremor :...............................................................................................................................
9) Data lain :............................................................................................................................
d. Disability
1) Kesadaran :..........................................................................................................................
2) GCS :...................................................................................................................................
3) Respon nyeri :......................................................................................................................
4) Respon bicara :....................................................................................................................
5) Reflek pupil :.......................................................................................................................
6) Spasme otot:........................................................................................................................
7) Parastesia :...........................................................................................................................
8) ROM :..................................................................................................................................
9) Data lain..............................................................................................................................
e. Exposure

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
 1) Cedera :...............................................................................................................................
2) Kerusakan jaringan :............................................................................................................
3) Dislokasi :............................................................................................................................
4) Luka :...................................................................................................................................
5) Odem :.................................................................................................................................
6) Data lain :............................................................................................................................
.............................................................................................................................................

2. Secondary Survey
a. Keadaan Umum
a. Status gizi : Gemuk Normal Kurus
Berat Badan...................................... Tinggi Badan :................................................
b. Sikap : Tenang Gelisah Menahan nyeri
b. Pemeriksaan Fisik
1) Breathing (B1)
a. Bentuk dada:..................................................................................................................
b. Frekuensi nafas :............................................................................................................
c. Kedalaman nafas :.........................................................................................................
d. Jenis pernafasan :..........................................................................................................
e. Pola nafas :....................................................................................................................
f. Retraksi otot bantu :......................................................................................................
g. Irama nafas :..................................................................................................................
h. Ekspansi paru :..............................................................................................................
i. Vocal fremitus :.............................................................................................................
j. Nyeri :............................................................................................................................
k. Batas paru :....................................................................................................................
l. Suara nafas :..................................................................................................................
m. Suara tambahan :...........................................................................................................
n. Pemeriksaan penunjang :...............................................................................................
.......................................................................................................................................
o. Data lain :......................................................................................................................
.......................................................................................................................................
2) Blood (B2)
a. Ictus cordis :..................................................................................................................
b. Nyeri :............................................................................................................................
c. Batas jantung :...............................................................................................................
d. Bunyi jantung :..............................................................................................................
e. Suara tambahan :...........................................................................................................
f. Pemeriksaan penunjang :...............................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
 .......................................................................................................................................
g. Data lain :......................................................................................................................
.......................................................................................................................................
3) Brain (B3)
a. Kesadaran :....................................................................................................................
b. GCS : ............................................................................................................................
c. Reflek fisiologis :..........................................................................................................
d. Reflek patologis :..........................................................................................................
e. Pemeriksaan penunjang :...............................................................................................
.......................................................................................................................................
f. Data lain :......................................................................................................................
.......................................................................................................................................
4) Bladder (B4)
a. Kebiasaan miksi :..........................................................................................................
b. Pola miksi :....................................................................................................................
c. Warna urine :.................................................................................................................
d. Jumlah urine :................................................................................................................
e. Pemeriksaan penunjang :...............................................................................................
.......................................................................................................................................
f. Data lain :......................................................................................................................
.......................................................................................................................................
5) Bowel (B5)
a. Bentuk abdomen :..........................................................................................................
b. Kebiasaan defekasi :......................................................................................................
c. Pola defekasi :...............................................................................................................
d. Warna feses :.................................................................................................................
e. Kolostomi :....................................................................................................................
f. Bising usus :..................................................................................................................
g. Pemeriksaan penunjang :...............................................................................................
.......................................................................................................................................
h. Data lain :......................................................................................................................
.......................................................................................................................................
6) Bone (B6)
a. Kekuatan otot:...............................................................................................................
b. Turgor :..........................................................................................................................
c. Odem :...........................................................................................................................
d. Nyeri :............................................................................................................................
e. Warna kulit :..................................................................................................................
f. Akral :............................................................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
 g. Sianosis :.......................................................................................................................
h. Parese :..........................................................................................................................
i. Alat bantu :....................................................................................................................
j. Pemeriksaan penunjang :...............................................................................................
.......................................................................................................................................
k. Data lain :......................................................................................................................
......................................................................................................................................

c. Terapi Medik
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
II. ANALISA DATA
NO. DATA ETIOLOGI MASALAH

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
III.DIAGNOSA KEPERAWATAN (SESUAI PRIORITAS)
1. .........................................................................................................................................................
2. .........................................................................................................................................................
3. .........................................................................................................................................................
4. .........................................................................................................................................................
5. .........................................................................................................................................................

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
IV. RENCANA TINDAKAN KEPERAWATAN

NO. DIAGNOSA NOC NIC

KEPERAWATAN (SMART)
TUJUAN (SMART) : Label NIC :

Aktifitas Keperawatan :

Label NOC :

Indikator :
Indeks
No. Indikator
1 2 3 4 5

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
V. IMPLEMENTASI
NO. HARI/ JAM TINDAKAN KEPERAWATAN PARAF
DX TGL

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
VI. EVALUASI
NO. NO. DX HARI/ JAM EVALUASI PARAF
TGL (SOAP)

Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019
Dep. Keperawatan Kritis Prodi Profesi Ners STIKES ICME Jombang 2018/2019