Post on 18-Feb-2015
ASUHAN KEPERAWATAN DI RUANG ICU RSUP DR KARIADI SEMARANG
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
Breathing
Circulation
Disability
Explosure
III. PENGKAJIAN SEKUNDER
A. Pemeriksaan fisik
1. Keadaan Umum
2. Tanda-tanda vital
Tanggal TD Nadi RR Suhu
3. Kepala
Bentuk
mata
hidung
telinga
mulut
leher
4. Dada
Inspeksi
Palpasi
Perkusi
Auskultasi
5. Abdomen
Inspeksi
Auskultasi
Perkusi
Palpasi
6. Ekstremitas
Ekstremitas Atas
Tanggal/ jam
Kanan Kiri
Kesemutan Edema Nyeri Kesemutan Edema Nyeri
Gerak
Kekuatan Otot :
Ekstremitas Bawah
Tanggal/ jam
Kanan Kiri
Kesemutan Edema Nyeri Kesemutan Edema Nyeri
Gerak
Kekuatan Otot :
7. Sistem Integumen
Tanggal/jam Warna kulit TurgorMukosa
bibirCapillary
refillKelainan
8. Genetalia
9. Sistem Persyarafam
a) Fungsi serebral/Status Mental
TanggalStatus mental
Tingkat kesadaran GCS Gaya bicara
Fungsi Intelektual Orientasi waktu Orientasi tempat Orientasi orang
Daya pikir Spontan, alamiah, masuk
akal Kesulitan berpikir Halusinasi
Status emosional Alamiah dan datar Pemarah Cemas Apatis
10. Eliminasi
11. Tingkat ketergantungan
Bathing
Dressing
Toileting
Transfering
Continence
Feeding
Indeks KATZ
12. Status Cairan
Tanggal Intake Output Balance Cairan
Parenteral :
Minum :
Makan :
Total :
Urine :
IWL :
Feses :
Muntah :
Drainase :
Total :
13. Pemeriksaan Penunjang
1) LaboratoriumPemeriksaan Nilai Satuan
Nilai Nilai Nilai
Hb 13 - 16 %
Ht 40 - 54 %
Eritrosit 45 - 65 jt/ mmk
Leukosit 4 - 11 ribu/ mmk
Trombosit 150 - 400 ribu/mmk
Creatinin 0.6 - 1.3 mg/ dL
Albumin 3.4 - 5 mg/ dL
Gula Sewaktu 80 - 120 mg/ dL
Ureum 15 - 39 mg/ dL
Na 136 - 145 mmol/ L
K 3.5 - 5.1 mmol/ L
Cl 98 - 107 mmol/ L
Cholesterol 50 - 200 mg/ dL
Trigliserid 30 - 150 mg/ dL
Waktu
protrombin
10 - 15 dtk
PPT kontrol 12.8
Waktu
tromboplastin
23.4 -
36.8
dtk
pH 7,35–3,45
pCO2 35 - 45 mmHg
pO2 83 - 103 mmHg
HCO3 18 - 23 Mmol/L
AADO2 <100
Laktat 0,4 - 2
Base Excess
14. Pemeriksaan Penunjang
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13.Therapy
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ANALISA DATA
Nama : No CM :
Usia : Dianosa Medis :
TANGGAL DATA FOKUS ETIOLOGI MASALAH TTD
PRIORITAS DIAGNOSA KEPERAWATAN
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RENCANA ASUHAN KEPERAWATAN
Nama : No CM :
Usia : Diagnosa Medis :
No
Dx.
DIAGNOSA
KEPERAWATAN
TUJUAN DAN KRITERIA
HASIL
INTERVENSI TTD
IMPLEMENTASI KEPERAWATAN
TGL/JAM NO.
DX.
IMPLEMENTASI RESPON TTD
EVALUASI
Nama : No CM :
Usia : Diagnosa Medis :
TGL/JAM NO
DX
EVALUASI ( SOAP ) TTD