ASUHAN KEPERAWATAN DI RUANG ICU
I.
PENGKAJIAN
Tanggal
masuk :
Tanggal
pengkajian :
A.
Identitas
Pasien
Nama :
Umur :
Alamat :
No Register :
Ruang :
Cara Pengkajian : Anamnesa,
pemeriksaan fisik, catatan rekam medis
Diagnosa
Medis :
Penanggung
jawab :
B.
Riwayat
Kesehatan
1.
Keluhan
utama
2.
Riwayat
penyakit sekarang
3.
Riwayat
penyakit dahulu
4.
Riwayat
penyakit keluarga
II.
PENGKAJIAN
PRIMER
Airway
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Breathing
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Circulation
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Disability
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Explosure
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III. PENGKAJIAN SEKUNDER
A.
Pemeriksaan
fisik
1.
Keadaan
Umum
2.
Tanda-tanda
vital
Tanggal
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TD
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Nadi
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RR
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Suhu
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3.
Kepala
Bentuk
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mata
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hidung
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telinga
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mulut
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leher
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4.
Dada
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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5.
Abdomen
Inspeksi
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Auskultasi
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Perkusi
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Palpasi
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6.
Ekstremitas
Ekstremitas Atas
Tanggal/ jam
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Kanan
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Kiri
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Kesemutan
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Edema
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Nyeri
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Kesemutan
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Edema
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Nyeri
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Gerak
Kekuatan
Otot :
Ekstremitas
Bawah
Tanggal/ jam
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Kanan
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Kiri
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Kesemutan
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Edema
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Nyeri
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Kesemutan
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Edema
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Nyeri
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Gerak
Kekuatan
Otot :
7.
Sistem
Integumen
Tanggal/jam
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Warna
kulit
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Turgor
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Mukosa bibir
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Capillary
refill
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Kelainan
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8.
Genetalia
9.
Sistem
Persyarafam
a) Fungsi
serebral/Status Mental
Tanggal
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Status mental
·
Tingkat kesadaran
·
GCS
·
Gaya bicara
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Fungsi Intelektual
·
Orientasi waktu
·
Orientasi tempat
·
Orientasi orang
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Daya pikir
·
Spontan,
alamiah, masuk akal
·
Kesulitan
berpikir
·
Halusinasi
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Status emosional
·
Alamiah dan
datar
·
Pemarah
·
Cemas
·
Apatis
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10. Eliminasi
11. Tingkat ketergantungan
Bathing
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Dressing
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Toileting
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Transfering
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Continence
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Feeding
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Indeks KATZ
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12. Status Cairan
Tanggal
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Intake
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Output
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Balance
Cairan
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Parenteral
:
Minum
:
Makan
:
Total
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Urine
:
IWL
:
Feses
:
Muntah
:
Drainase
:
Total
:
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13. Pemeriksaan Penunjang
1)
Laboratorium
Pemeriksaan
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Nilai
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Satuan
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Nilai
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Nilai
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Nilai
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Hb
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13
- 16
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%
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Ht
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40
- 54
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%
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Eritrosit
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45
- 65
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jt/
mmk
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Leukosit
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4
- 11
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ribu/
mmk
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Trombosit
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150
- 400
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ribu/mmk
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Creatinin
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0.6
- 1.3
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mg/
dL
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Albumin
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3.4
- 5
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mg/
dL
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Gula
Sewaktu
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80
- 120
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mg/
dL
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Ureum
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15
- 39
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mg/
dL
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Na
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136
- 145
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mmol/
L
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K
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3.5
- 5.1
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mmol/
L
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Cl
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98
- 107
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mmol/
L
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Cholesterol
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50
- 200
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mg/
dL
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Trigliserid
|
30
- 150
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mg/
dL
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Waktu
protrombin
|
10
- 15
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dtk
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PPT
kontrol
|
12.8
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Waktu
tromboplastin
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23.4
- 36.8
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dtk
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pH
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7,35–3,45
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pCO2
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35
- 45
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mmHg
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pO2
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83
- 103
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mmHg
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HCO3
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18
- 23
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Mmol/L
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AADO2
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<100
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Laktat
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0,4
- 2
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Base
Excess
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14. Pemeriksaan Penunjang
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13.Therapy
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ANALISA DATA
Nama : No
CM :
Usia : Dianosa
Medis :
TANGGAL
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DATA
FOKUS
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ETIOLOGI
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MASALAH
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TTD
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PRIORITAS DIAGNOSA KEPERAWATAN
1.
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2. ………………………………………………………………………………………………………………………………………...................
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3.
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4
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5.
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6.
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RENCANA ASUHAN KEPERAWATAN
Nama : No
CM :
Usia : Diagnosa
Medis :
No
Dx.
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DIAGNOSA
KEPERAWATAN
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TUJUAN
DAN KRITERIA HASIL
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INTERVENSI
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TTD
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IMPLEMENTASI KEPERAWATAN
TGL/JAM
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NO.
DX.
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IMPLEMENTASI
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RESPON
|
TTD
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EVALUASI
Nama : No
CM :
Usia : Diagnosa
Medis :
TGL/JAM
|
NO
DX
|
EVALUASI
( SOAP )
|
TTD
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