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