ASUHAN KEPERAWATAN PADA.....

DENGAN ....................................
DI RUANGAN CICU RSUP
DR. HASAN SADIKIN
BANDUNG
I.

PENGKAJIAN
1. Identitas Pasien
Nama
Umur
Jenis kelamin
Agama
BB
No. Rekam Medik
Tanggal Pengkajian
Diagnosa Medik

:
:
:
:
:
:
:
:

2. Riwayat penyakit

Keluhan Utama
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Riwayat penyakit sekarang :
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Riwayat penyakit dahulu :
........................................................................................................................
........................................................................................................................

........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Riwayat penyakit keluarga :
........................................................................................................................
........................................................................................................................
3. Pengkajian Sistem
a. HEENT
.................................................................................................................
.................................................................................................................

b.

c.

d.

e.

f.

g.

h.

.................................................................................................................
.................................................................................................................
Kaldiovaskuler
.................................................................................................................
.................................................................................................................
.................................................................................................................
Pernafasan
.................................................................................................................
.................................................................................................................
.................................................................................................................
Pencernaan
..................................................................................................................
................................................................................................................
Genitalia
..................................................................................................................
................................................................................................................
Muskuloskeletal
.................................................................................................................
.................................................................................................................
Neurologis
.................................................................................................................
.................................................................................................................
Psikiatri

.................................................................................................................
4. Data Penunjang
a. Pemeriksaan Laboratorium
Tanggal

Pemeriksaan

Hasil

Nilai Rujukan Satuan

b. Pemeriksaan ST Scan

.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
c. Pemeriksaan Thoraks
.................................................................................................................
.................................................................................................................
.................................................................................................................

5. Terapi
No
1.

Tanggal

Nama therapi

Dosis

2.

II.

ANALISA DATA
No
1

Tanggal

Data

Etiologi

Masalah

III. DIAGNOSA KEPERAWATAN

IV. RENCANA KEPERAWATAN

No
1.

2.

Diagnosa Keperawatan

Tujuan

Intervensi

3.

V. IMPLEMENTASI KEPERAWATAN
Tanggal/Dx

Implementasi

Respon

TTD

VI. EVALUASI
Tanggal

Dx. Kep

SOAP

TTD

Laporan Kasus
Asuhan Keperawatan pada Ny. D dengan HELLP Syndrome
di Ruang General Intensive Care Unit
Rumah Sakit Hasan Sadikin
Bandung

Pembimbing: Ayu Prawesti, S.Kp, M. Kep

OLEH
Barkah Waladani 220120140020
Hendra Harwadi 220120140017
Rusda Adiwijaya

220120140051

Program Magister Keperawatan

Fakultas Keperawatan
Universitas Padjadjaran
Bandung

2015