Format Askep ICU

ASUHAN KEPERAWATAN DI RUANG ICU RSUP DR KARIADI SEMARANG I.

PENGKAJIAN

Tanggal masuk

:

Tan Tanggal ggal pengk engkaj ajia ian n

:

A. Iden Identi tita tass Pas Pasie ien n

 Nama

:

Umur

:

Alamat

:

 No Register

:

Ruang

:

Cara Pengkajian Pengkajian

: Anamnesa, Anamnesa, pemeriksaan pemeriksaan fisik, catatan rekam medis

Diagnosa Medis

:

Penang Penanggun gung g jawab jawab :

3. Riwayat penyakit dahulu

4. Riwayat penyakit keluarga

II.

PENGKAJIAN PRIMER  

Airway

Breathing

1. Keadaan Umum

2. Tanda-tanda vital Tanggal

3. Kepala Bentuk 

mata

hidung

TD

Nadi

RR

Suhu

Palpasi

6. Ekstremitas Ekstremitas Atas Tanggal/  jam

Kanan Kesemutan

Edema

Kiri Nyeri

Kesemutan

Edema

Nyeri

Gerak  Kekuatan Otot : Ekstremitas Bawah Tanggal/  jam

Kanan Kesemutan

Gerak 

Edema

Kiri Nyeri

Kesemutan

Edema

Nyeri

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

12. Status Cairan Tanggal

Intake Parenteral :

Output Urine : IWL : Feses : Muntah : Drainase : Total :

Minum : Makan : Total :

Balance Cairan

Cholesterol Trigliserid Waktu

50 - 200 30 - 150 10 - 15

mg/ dL mg/ dL dtk  

 protrombin PPT kontrol Waktu

12.8 23.4 -

dtk 

tromboplastin  pH

36.8 7,35– 

 pCO2  pO2 HCO3 AADO2 Laktat Base Excess

3,45 35 - 45 83 - 103 18 - 23 <100 0,4 - 2

mmHg mmHg Mmol/L

14. Pemeriksaan Penunjang

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

13.Therapy

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

ANALISA DATA

 Nama :

No CM :

Usia

Dianosa Medis :

:

TANGGAL

DATA FOKUS

ETIOLOGI

MASALAH

TTD

PRIORITAS DIAGNOSA KEPERAWATAN

1.

………………………………………………………………………………………………………………………………………................... …………………………………………………………………………………………………………………………………………………...

2.

………………………………………………………………………………………………………………………………………................... …………………………………………………………………………………………………………………………………………………...

3.

………………………………………………………………………………………………………………………………………................... …………………………………………………………………………………………………………………………………………………...

4

………………………………………………………………………………………………………………………………………................... …………………………………………………………………………………………………………………………………………………...

5.

………………………………………………………………………………………………………………………………………................... …………………………………………………………………………………………………………………………………………………...

6.

………………………………………………………………………………………………………………………………………................... …………………………………………………………………………………………………………………………………………………...

RENCANA ASUHAN KEPERAWATAN

 Nama :

No CM :

Usia

Diagnosa Medis :

 No

: DIAGNOSA

Dx. 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