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ASUHAN KEPERAWATAN

PADA …….. DENGAN DIAGNOSA MEDIS
……………..………………………….
DI INTENSIVE CARE UNIT (ICU) RS ROEMANI MUHAMMADIYAH
Disusun untuk Memenuhi Tugas pada Praktik Klinik Stase Gawat Darurat
Pembimbing Klinik : …………………………..….
Pembimbing Akademik : ……………………………...
Pembimbing Akademik : ……………………………...

Oleh:
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PROGRAM PENDIDIKAN PROFESI NERS XXVI
JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
2016
ASUHAN KEPERAWATAN

Tanggal pengkajian : ............................................. Jam : ............................
Tanggal masuk : ............................................. Jam : ............................
Ruang : ....................................................................................

A. Identitas
1. Klien/Pasien
a. Nama (Inisial) : ....................................................................
b. No. Rekam medik : ....................................................................
c. Umur : ....................................................................
d. Jenis kelamin : .....................................................................
e. Agama : .....................................................................
f. Pendidikan : .....................................................................
g. Pekerjaan : .....................................................................
h. Suku : .....................................................................
i. Bahasa : .....................................................................
j. Alamat : .....................................................................
k. Diagnosa Medis : .....................................................................

2. Identitas Penanggung Jawab
a. Nama (Inisial) : …...………………….…………………….
b. Umur : …………………………………………….
c. Jenis kelamin : …………………………………………….
d. Alamat : ..……………………………………………
e. Hubungan dengan klien : ..……………………………………

B. Pengkajian Primer
1. Airway
Look :
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Listen :
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Feel :
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2. Breathing
Look :

..………. Pengkajian Sekunder 1. 5.. Circulation : ……………………………………………………………………..………. …………………………………………………………………….... Feel : ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………... C. ……………………………………………………………………... …………………………………………………………………….……….………. …………………………………………………………………….………..……….. ..……….………..………. …………………………………………………………………….……….………. …………………………………………………………………….………. ……………………………………………………………………. …………………………………………………………………….. …………………………………………………………………….... …………………………………………………………………….....………..……….………. 4... Exposure : ……………………………………………………………………. ……………………………………………………………………..……….. …………………………………………………………………….. …………………………………………………………………….. …………………………………………………………………….....………. ……………………………………………………………………. …………………………………………………………………….....……….………. Disability : …………………………………………………………………….……….……….. ……………………………………………………………………. ……………………………………………………………………...……….……….……….. Listen : ……………………………………………………………………........………. Anamnesis (SAMPLE) S (Signs and Symptoms) …………………………………………………………………….………...……….. ……………………………………………………………………....………...……….. …………………………………………………………………….………. …………………………………………………………………….………....... 3.……….. ……………………………………………………………………...………... ……………………………………………………………………. …………………………………………………………………….. ……………………………………………………………………. …………………………………………………………………….……….………. A (Allergies) ……………………………………………………………………. …………………………………………………………………….………...

.………...……….………. ……………………………………………………………………... ……………………………………………………………………..………. …………………………………………………………………….....……….. ……………………………………………………………………. L (Last Meal) ……………………………………………………………………..………...………. ……………………………………………………………………..……….... Kepala ... …………………………………………………………………….. …………………………………………………………………….……….………. …………………………………………………………………….……….………. …………………………………………………………………….. …………………………………………………………………….……….. ……………………………………………………………………....  RR : …………………......……….. M (Medications) ……………………………………………………………………. a..……………. ……………………………………………………………………. Vital sign:  TD : ……. ……………………………………………………………………. …………………………………………………………………….………. ……………………………………………………………………. …………………………………………………………………….  Suhu : …………………..... ……………………………………………………………………. P (Pertinent Medical History) ……………………………………………………………………...………. Kesadaran : …………………………………………………………………….………. ……………………………………………………………………. ……………………………………………………………………..……….………. …………………………………………………………………….……….......……….………..……….. …………………………………………………………………….. E (Events) ……………………………………………………………………. 2.. Pemeriksaan Fisik: Keadaan Umum : …………………………………………………………………….  HR : ………………….……….………..... …………………………………………………………………….……….....………...………. ……………………………………………………………………. …………………………………………………………………….. ……………………………………………………………………....……….……….………..

…………………………………………………………………….……. d.…….……. …………………………………………………………………….……. …………………………………………………………………….……. …………………………………………………………………….……. Mata …………………………………………………………………….……. f.…….……. ……………………………………………………………………. ……………………………………………………………………. Mulut dan Gigi …………………………………………………………………….…….……. ……………………………………………………………………. …………………………………………………………………….…….…….…….…….……. ……………………………………………………………………. …………………………………………………………………….……. e.…….…….…….…….……. c.……. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. g. …………………………………………………………………….……. …………………………………………………………………….……. …………………………………………………………………….…….……. ……………………………………………………………………. …………………………………………………………………….…….……. ……………………………………………………………………. …………………………………………………………………….……. …………………………………………………………………….……. …………………………………………………………………….…….……. ……………………………………………………………………. . …………………………………………………………………….……. …………………………………………………………………….…….……. Telinga ……………………………………………………………………. ……………………………………………………………………. Leher ……………………………………………………………………. ……………………………………………………………………. b.…….……. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….……. ……………………………………………………………………. Hidung ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….……. Dada dan paru …………………………………………………………………….

……. …………………………………………………………………….……. …………………………………………………………………….……. i. …………………………………………………………………….……. …………………………………………………………………….……. ……………………………………………………………………. …………………………………………………………………….…….……. …………………………………………………………………….……. …………………………………………………………………….…….…….……. …………………………………………………………………….…….…….…….…….…….……. …………………………………………………………………….……. ……………………………………………………………………. k.……. Ekstremitas  Ekstremitas Atas ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ………………………………………………………………………  Ekstremitas Bawah ……………………………………………………………………… ……………………………………………………………………… . ……………………………………………………………………. …………………………………………………………………….……. Genetalia …………………………………………………………………….…….…….…….……. ……………………………………………………………………. h.…….……. …………………………………………………………………….…….……. ……………………………………………………………………. …………………………………………………………………….……. Jantung …………………………………………………………………….…….……. …………………………………………………………………….…….……. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….……. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. Abdomen ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. j.

……………………………………………………………………. …………………………………………………………………….……. ……………………………………………………………………. Nutrisi dan Cairan …………………………………………………………………….……. Pengkajian Fungsional a.……. c.……. Eliminasi …………………………………………………………………….……. ……………………………………………………………………. Oksigenasi ……………………………………………………………………. …………………………………………………………………….……. …………………………………………………………………….……. …………………………………………………………………….…….……. ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….…….……. ……………………………………………………………………… ……………………………………………………………………… 3. ……………………………………………………………………. ……………………………………………………………………. Termoregulasi …………………………………………………………………….……. …………………………………………………………………….…….……. ……………………………………………………………………. …………………………………………………………………….……. e. d. ……………………………………………………………………. …………………………………………………………………….…….…….…….…….……. ……………………………………………………………………. ……………………………………………………………………. b. …………………………………………………………………….…….…….…….…….…….……. ……………………………………………………………………. …………………………………………………………………….……. ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….…….……. ……………………………………………………………………. …………………………………………………………………….…….……. …………………………………………………………………….…….……. …………………………………………………………………….……. Aktifitas Latihan/Mobilisasi Keterangan 0 1 2 3 4 . …………………………………………………………………….…….…….……. ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….

……………………………………………………………………. Mandi Berpakaian Eliminasi Makan dan Minum Mobilisasi Ambulasi Keterangan : 1 : mandiri 2 : Dibantu sebagian 3 : Perlu bantuan orang lain 4 : Perlu bantuan orang lain dan alat Keterangan : 4 : tergantung penuh ……………………………………………………………………. Rasa Aman dan Nyaman ……………………………………………………………………. …………………………………………………………………….……. …………………………………………………………………….……. ……………………………………………………………………. h. …………………………………………………………………….…… …………………………………………………………………….…….……. g. ……………………………………………………………………. ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….…….…… …………………………………………………………………….…….…….……. Higiene Keterangan Sebelum sakit Saat sakit . j. ……………………………………………………………………. ……………………………………………………………………. Koping.…….……. ……………………………………………………………………. Spiritual …………………………………………………………………….……. ……………………………………………………………………. ……………………………………………………………………. Seksualitas …………………………………………………………………….…….…….…… f.…… …………………………………………………………………….…….……. Psikososial (Stress.…….……. dan Konsep Diri) ……………………………………………………………………. …………………………………………………………………….…….……. …………………………………………………………………….……. ……………………………………………………………………. i.…….……. …………………………………………………………………….

…………………………………………………………………….……. .……. ……………………………………………………………………. ……………………………………………………………………. Kebutuhan Belajar ……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….…….……. …………………………………………………………………….…….……. ……………………………………………………………………. …………………………………………………………………….……. …………………………………………………………………….…….…….……. ……………………………………………………………………. …………………………………………………………………….……. ……………………………………………………………………. …………………………………………………………………….……. m. …………………………………………………………………….…….……. ……………………………………………………………………. ……………………………………………………………………. Rekreasi …………………………………………………………………….……. ……………………………………………………………………. Aktualisasi Diri ……………………………………………………………………. Mandi Ganti Pakaian Mencuci rambut Menggosok gigi Keterangan : …………………………………………………………………….…….…….……. …………………………………………………………………….……. ……………………………………………………………………. Istirahat Tidur ……………………………………………………………………. k.…….……. ……………………………………………………………………. n.……. …………………………………………………………………….…….……. l. …………………………………………………………………….…….…….…….

Pemeriksaan Penunjang Hari/ Tanggal : …………….D. Jenis Pemeriksaan Hasil Satuan Nilai No ..

E. Terapi Jenis Terapi Dosis Rute Indikasi & Cara Kerja Kontraindikasi .

.

Analisa Data No Data Masalah Etiologi .F.

.

Perencanaan No Tgl/Jam Dx Kep Intervensi Tujuan dan Kriteria Hasil In .G.

Implementasi Tgl/ Jam No.H. Dx Implementasi Respon .

.

Evaluasi No Tgl/Jam Dx Keperawatan Evaluasi .I.

.

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………………………………………………………………………………………… ………………………………………..... ………………………………………………………………………………………… ………………………………………. ………………………………………………………………………………………… ……………………………………….. ………………………………………………………………………………………… ………………………………………. ………………………………………………………………………………………… ……………………………………….... ………………………………………………………………………………………… ……………………………………….. ………………………………………………………………………………………… ………………………………………. ………………………………………………………………………………………… ………………………………………..J. ………………………………………………………………………………………… ………………………………………... ………………………………………………………………………………………… ………………………………………. ………………………………………………………………………………………… ………………………………………. ………………………………………………………………………………………… ……………………………………….. .. Pembahasan ………………………………………………………………………………………… ………………………………………. ………………………………………………………………………………………… ………………………………………... ………………………………………………………………………………………… ………………………………………. ………………………………………………………………………………………… ……………………………………….

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

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

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