ASUHAN KEPERAWATAN INTENSIF

DI RUANG RSUP SANGLAH DENPASAR

OLEH

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS UDAYANA
DENPASAR
2017
 PENGKAJIAN KEPERAWATAN INTENSIF

Tanggal/Jam : ............................... No. RM : ..............................

Ruangan : ............................... Diagnosa Medis : ..............................
Nama/Inisial : ............................ Jenis Kelamin : Laki-laki/Perempuan
RIWAYAT SAKIT DAN KESEHATAN IDENTITAS

Umur : ..........tahun Status Perkawinan : ..................................

Agama : ............................ Sumber Informasi : ..................................
Pendidikan : ............................ Hubungan : ..................................
Pekerjaan : ............................
Suku/ Bangsa : ............................
Alamat : ...........................................................................................................
Keluhan utama saat MRS :
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Keluhan utama saat pengkajian :
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Riwayat penyakit saat ini :
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Riwayat Allergi :
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Riwayat Pengobatan :
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Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga:
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Jalan Nafas : Paten Tidak Paten
Obstruksi : Lidah Cairan Benda Asing Tidak Ada
Muntahan Darah Oedema
Suara Nafas: Snoring Gurgling Stridor Tidak ada
Nafas : Spontan Tidak Spontan
Gerakan dinding dada: Simetris Asimetris
Irama Nafas : Cepat Dangkal Normal
Pola Nafas : Teratur Tidak Teratur
Jenis : Dispnoe Kusmaul Cyene Stoke Lain
Suara Nafas : Vesikuler Stidor Wheezing Ronchi
Sesak Nafas : Ada Tidak Ada
BREATHING

Cuping hidung Ada Tidak Ada

Retraksi otot bantu nafas : Ada Tidak Ada
Pernafasan : Pernafasan Dada Pernafasan Perut
Batuk : Ya Tidak ada
Sputum: Ya , Warna: ... ... ... Konsistensi: ... ... ... Volume: ... Bau:
Tidak
RR : ... ... x/mnt
Alat bantu nafas: OTT ETT Trakeostomi
Ventilator, Keterangan: ... ... ...
Oksigenasi : ... ... lt/mnt Nasal kanul Simpel mask Non RBT mask
RBT Mask Tidak ada
Lain: ............................................................................................................................
Masalah Keperawatan:


 Nadi : Teraba Tidak teraba N: x/mnt
Tekanan Darah : mmHg
Pucat : Ya Tidak
Sianosis : Ya Tidak
CRT : < 2 detik > 2 detik
Akral : Hangat Dingin S: ... ...C
Pendarahan : Ya, Lokasi: ... ... Jumlah ... ...cc Tidak
Turgor : Elastis Lambat

B Diaphoresis: Ya Tidak
L Riwayat Kehilangan cairan berlebihan: Diare Muntah Luka bakar
O IVFD : Ya Tidak, Jenis cairan:
O Lain:
D Masalah Keperawatan:


Kesadaran: Composmentis Delirium Somnolen Apatis Koma
GCS : Eye ... Verbal ... Motorik ...
Pupil : Isokor Unisokor Pinpoint Medriasis
Refleks Cahaya: Ada Tidak Ada
Refleks fisiologis: Patela (+/-) Lain-lain
Refleks patologis : Babinzky (+/-) Kernig (+/-) Lain-lain ... ...
BRAIN

Refleks pada bayi: Refleks Rooting (+/-) Refleks Moro (+/-)

(Khusus PICU/NICU) Refleks Sucking (+/-)
Bicara : Lancar Cepat Lambat
Tidur malam : jam Tidur siang : jam
Ansietas : Ada Tidak ada
Lain : ...........................................................................................................................
Masalah Keperawatan:


 Nyeri pinggang: Ada Tidak
BAK : Lancar Inkontinensia Anuri
Nyeri BAK : Ada Tidak ada
BLADDER

Frekuensi BAK : Warna: ... ... Darah : Ada Tidak ada

Kateter : Ada Tidak ada, Urine output: ... ...
Lain: ............................................................................................................................
Masalah Keperawatan:


TB : ... ...cm BB : ... ...kg
Nafsu makan : Baik Menurun
Keluhan : Mual Muntah Sulit menelan
Makan : Frekuensi ... ...x/hr Jumlah : ... ... porsi
Minum : Frekuensi ... ... gls /hr Jumlah : ... ... cc/hr
BOWEL

Perut kembung : Ya Tidak

BAB : Teratur Tidak
Frekuensi BAB : ... ...x/hr Konsistensi: ... ... .. Warna: ... ... darah (+/-)/lendir(+/-)
Lain : ...........................................................................................................................

Masalah Keperawatan:


 Nyeri : Ada Tidak
Problem : .......................... Qualitas/ Quantitas : ..........................
Regio : .......................... Skala : ..........................
Timing : .......................... Kekuatan otot : ..........................
BONE

Deformitas : Ya Tidak Lokasi ... ...

Contusio : Ya Tidak Lokasi ... ...
(Muskuloskletal & Integumen)

Abrasi : Ya Tidak Lokasi ... ...

Penetrasi : Ya Tidak Lokasi ... ...
Laserasi : Ya Tidak Lokasi ... ...
Edema : Ya Tidak Lokasi ... ...
Luka Bakar : Ya Tidak Lokasi ... ...
Grade : ... ... %

Jika ada luka/ vulnus, kaji:

Luas Luka : ... ...
Warna dasar luka: ... ...
Kedalaman : ... ...

Aktivitas dan latihan :0 1 2 3Keterangan:

4
0; Mandiri
Makan/minum :0 1 2 31; Alat
4bantu
2; Dibantu orang lain
Mandi :0 1 2 33; Dibantu
4 orang lain dan
alat
Toileting :0 1 2 34; Tergantung
4 total
Berpakaian :0 1 2 3 4
Mobilisasi di tempat tidur :0 1 2 3 4
Masalah Keperawatan:

 (Fokus pemeriksaan pada daerah trauma/sesuai kasus non trauma)

Kepala dan Wajah :
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Leher :
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Dada :
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H ___________________________________________________________________
E ___________________________________________________________________
A
D
Abdomen dan Pinggang :
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O ___________________________________________________________________
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Masalah Keperawatan:

Hasil Laboratorium :
a. Hasil Pemeriksaan Darah Lengkap

Hasil
No Parameter Satuan Nilai rujukan

1 WBC K/uL 4,10 11,0

2 Neu % 2,50 7,50 47,0 80,0
3 Lym % 1,00 4,00 13,0 40,0
4 Mono % ,100 1,20 2,00 11,00
5 Eos % 0,00 - ,500 0,00 5,00
6 Baso % 0,00 - ,100 0,00 2,00
7 RBC M/uL 4,00 5,20
8 HGB g/dL 12,0 16,0
9 Hct % 36,0 46,0
10 MCV fL 80,0 100,
11 MCH Pg 26,0 34,0
12 MCHC g/dL 31,0 36,0
13 RDW % 11,6 14,8
14 PLT K/uL 140 440
15 MPV fL 0,00 - 100
16 Hemoglobin Lk: 13-18, P: 11,5-16,5
17 Leukosit 4000-11.000
18 Trombosit 15.000-400.000

b. Hasil Pemeriksaan AGD

Hasil
No Parameter Satuan Nilai rujukan Remark

1 pH - 7,35 7,45
2 PCO2 mmHg 35,00 -45,00
3 PO2 mmHg 80,00 100,00
4 HCO3- mmol/L 22,00 26,00
5 BE (B) mmol/L -2 - 2
6 SPO2 % 95 % - 100%
7 TCo2 mmol/L 24-30
8 K mmol/L 3,5-5
9 Na mmol/L 135-145
10 Cl mmol/L 95-105
12 Ca mmol/L 1-1,25
13 Hb g/dL 11,5-15,5

c. Hasil Pemeriksaan Kimia Klinik

Masalah Keperawatan:


ANALISA DATA
Data
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DIAGNOSA KEPERAWATAN
Praktik Profesi Keperawatan Intensif
Program Studi Ilmu Keperawatan B Tahun 2015
Penyebab/Interpretasi
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 Program Studi Ilmu Keperawatan B Tahun 2015

No Tanggal Diagnosa Keperawatan Tanggal Ttd

Dx Muncul Teratasi

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Praktik Profesi Keperawatan Intensif

 Program Studi Ilmu Keperawatan B Tahun 2015

PERENCANAAN
Hari/ No Rencana Keperawatan
Tanggal Dx Tujuan dan Kriteria Hasil Intervensi Rasional

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Praktik Profesi Keperawatan Intensif

 Program Studi Ilmu Keperawatan B Tahun 2015

Hari/ No Rencana Keperawatan

Tanggal Dx Tujuan dan kriteria hasil Intervensi Rasional

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Praktik Profesi Keperawatan Intensif

 Program Studi Ilmu Keperawatan B Tahun 2015

PELAKSANAAN
Hari/ No
Jam Tindakan Keperawatan Respon Klien TTD
Tanggal Dx

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Praktik Profesi Keperawatan Intensif

 Program Studi Ilmu Keperawatan B Tahun 2015

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Praktik Profesi Keperawatan Intensif

 Program Studi Ilmu Keperawatan B Tahun 2015

CATATAN PERKEMBANGAN
Hari/ No Jam S O A P
Tgl Dx

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Praktik Profesi Keperawatan Intensif