ASUHAN KEPERAWATAN PADA

DENGAN ..............DI RUANG INTENSIF CARE UNIT

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

Disusun Oleh :
NANDA PUTRI NUR AZIZ
PN190196

PROGRAM STUDI ILMU KEPERAWATAN & NERS

SEKOLAH TINGGI ILMU KESEHATAN WIRA HUSADA
YOGYAKARTA
2020
 LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN PADA ....

DENGAN .............. DI RUANG INTENSIF CARE UNIT
............

Asuhan keperawatan ini telah dibaca, diperiksa pada

Hari/tanggal :

Pebimbing Klinik Mahasiswa Praktikan

(………………………………….) (Nanda Putri)

Mengetahui
Pembimbing Akademik

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 FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT
DI ICU / ICCU
STIKES WIRA HUSADA YOGYAKARTA

Nama mahasiswa : _____________________________________

NIM : _____________________________________
Tempat praktek : _____________________________________
Tanggal Pengkajian : _____________________________________
Tanggal Praktik : _____________________________________

A. Identitas Pasien
Nama : ______________________________________
Tempat/tgl lahir : ______________________________________
Umur : ______________________________________
Agama : ______________________________________
Alamat : ______________________________________
Pekerjaan : ______________________________________
Jenis Kelamin : ______________________________________
Diagnosa Medis : ______________________________________
Tgl Masuk RS : ______________________________________

Penaggungjawab
Nama : ______________________________________
Tempat/tgl lahir : ______________________________________
Umur : ______________________________________
Agama : ______________________________________
Alamat : ______________________________________
Pekerjaan : ______________________________________
Jenis Kelamin : ______________________________________
Hubungan dengan pasien : ______________________________________

B. Riwayat Kesehatan
1. Keluhan Utama :
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 2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Dahulu :
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4. Riwayat Penyakit Keluarga :

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5. Genogram

C. Pengkajian Pemenuhan Kebutuhan Dasar Manusia menurut Gordon (11 pola)

1. Pola Persepsi dan pemeliharaan kesehatan
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2. Pola Nutrisi
Sebelum sakit :……………………………………………………………..............
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 Selama Sakit : ……………………………………………………………………….
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3. Pola Eliminasi
Sebelum sakit :…………………………………………………………….................
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Selama Sakit : ……………………………………………………………………….
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4. Aktivitas dan latihan
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5. Tidur dan istirahat
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6. Sensori, persepsi, dan kognitif
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7. Konsep diri
a. Identitas diri :………………………………………………………………………
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b. Gambaran diri :……………………………………………………………………
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c. Ideal diri :…………………………………………………………………………..
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d. Harga diri :…………………………………………………………………………
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e. Peran diri :…………………………………………………………………………
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8. Seksual dan reproduksi
Sebelum sakit :…………………………………………………………….................
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Selama Sakit : …………………………………………………………………………
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9. Pola peran hubungan
Sebelum sakit :……………………………………………………………..............
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Selama Sakit : ………………………………………………………………………..
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10. Manajemen koping stress
Sebelum sakit :……………………………………………………………..............
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Selama Sakit : ……………………………………………………………………….
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11. Sistem nilai dan keyakinan
 Sebelum sakit :……………………………………………………………..............
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Selama Sakit : ………………………………………………………………………..
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D. Pemeriksaan Fisik
1. Tingkat kesadaran :
0
2. TTV :S C, Nadi x/mnt, RR x/mnt,
TD mmhg
Nyeri (PQRST)

3. Kepala : …………………………………………………………………
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4. Mata, telinga, hidung :…………………………………………………………………
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5. Mulut : …………………………………………………………………
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6. Leher : ……………………………………………………………….
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7. Dada / thoraks : ……………………………………………………………….
Jantung
Inspeksi :……………………………………………...........................
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Palpasi :………………………………………………………………..
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perkusi :………………………………………………………………..
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Auskultasi :………………………………………………………………..
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Paru-paru
Inspeksi :……………………………………………...........................
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Palpasi :………………………………………………………………..
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perkusi :………………………………………………………………..
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Auskultasi :………………………………………………………………..
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8. Abdomen :
Inspeks :……………………………………………...........................
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Auskultasi :………………………………………………………………..
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Palpasi :………………………………………………………………..
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perkusi :…………………………………………………………………
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9. Genitalia : ……………………………………………………………….
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10. Ekstremitas :
Atas : …………….……………………………………………………………………
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Bawah :...........................................................................................................
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11. Kulit : ……………………………………………………………………………………
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E. Pemeriksaan penunjang :

F. Terapi medik
G. Analisa Data :

ANALISA MASALAH

Data Etiologi Problem

DS :

DO

DS :

DO

DS :

DO
H. Diagnosa Keperawatan
1.
2.
3.
I. Intervensi
N DIAGNOSA NOC NIC
O
N DIAGNOSA NOC NIC
O
N DIAGNOSA NOC NIC
O
J. Implementasi dan Evaluasi
Waktu Dx Implementasi Evaluasi
Tgl Jam
 Waktu Dx Implementasi Evaluasi
Tgl Jam
 Waktu Dx Implementasi Evaluasi
Tgl Jam