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ASUHAN KEPERAWATAN PADA PASIEN ................................................................ DENGAN DIAGNOSA MEDIS .............................. DI RUANG .............................................
DEPARTEMEN KEPERAWATAN KRITIS
Disusun Oleh: ...............................................
PROGRAM STUDI PROFESI NERS SEKOLAH TINGGI ILMU KESEHATAN INSAN CENDEKIA MEDIKA JOMBANG 2018/2019 Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
PRAKTIK PROFESI NERS PROGRAM STUDI PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN INSAN CENDEKIA MEDIKA JOMBANG Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886 Email: [email protected]
Asuhan Keperawatan pada pasien ................................ Dengan Diagnosa Medis ................................. di Ruang...........................................
I. PENGKAJIAN A. Tanggal Masuk
: ......................................................................................................................
B. Jam masuk
: ......................................................................................................................
C. Tanggal Pengkajian
: ......................................................................................................................
D. Jam Pengkajian
: ......................................................................................................................
E. No.RM
: ......................................................................................................................
F. Identitas 1. Identitas pasien a. Nama
:.............................................................................................................
b. Umur
:.............................................................................................................
c. Jenis kelamin
:.............................................................................................................
d. Agama
:.............................................................................................................
e. Pendidikan
:.............................................................................................................
f. Pekerjaan
:.............................................................................................................
g. Alamat
:.............................................................................................................
h. Status Pernikahan
:.............................................................................................................
2. Penanggung Jawab Pasien a. Nama
:.............................................................................................................
b. Umur
:.............................................................................................................
c. Jenis kelamin
:.............................................................................................................
d. Agama
:.............................................................................................................
e. Pendidikan
:.............................................................................................................
f. Pekerjaan
:.............................................................................................................
g. Alamat
:.............................................................................................................
h. Hub. Dengan PX
:.............................................................................................................
G. Pengkajian 1. Primary Survey a. Airway 1) Posisi kepala : ..................................................................................................................... Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
2) Secret/sputum : ................................................................................................................... 3) Reflek batuk : ..................................................................................................................... 4) Lidah jatuh :........................................................................................................................ 5) Benda asing : ...................................................................................................................... 6) Gigi : ................................................................................................................................... 7) Epistaksis : .......................................................................................................................... 8) Data lain : ........................................................................................................................... b. Breathing 1) Frekuensi nafas : ................................................................................................................. 2) Irama nafas : ....................................................................................................................... 3) Suara nafas : ....................................................................................................................... 4) Kedalaman nafas : .............................................................................................................. 5) Pola nafas : ......................................................................................................................... 6) Jenis pernafasan :................................................................................................................ 7) Suara tambahan : ................................................................................................................ 8) Ekspansi dada : ................................................................................................................... 9) Batuk : ................................................................................................................................ 10) Data lain : ........................................................................................................................... c. Circulation 1) Tekananan darah : .............................................................................................................. 2) Bunyi jantung : ................................................................................................................... 3) Akral : ................................................................................................................................. 4) Sianosis :............................................................................................................................. 5) CRT : .................................................................................................................................. 6) Suhu : .................................................................................................................................. 7) Odem : ................................................................................................................................ 8) Tremor : .............................................................................................................................. 9) Data lain : ........................................................................................................................... d. Disability 1) Kesadaran : ......................................................................................................................... 2) GCS : .................................................................................................................................. 3) Respon nyeri : ..................................................................................................................... 4) Respon bicara : ................................................................................................................... 5) Reflek pupil : ...................................................................................................................... 6) Spasme otot: ....................................................................................................................... 7) Parastesia : .......................................................................................................................... 8) ROM : ................................................................................................................................. 9) Data lain ............................................................................................................................. e. Exposure Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
1) Cedera :............................................................................................................................... 2) Kerusakan jaringan : ........................................................................................................... 3) Dislokasi : ........................................................................................................................... 4) Luka : .................................................................................................................................. 5) Odem : ................................................................................................................................ 6) Data lain : ........................................................................................................................... ............................................................................................................................................
2. Secondary Survey a. Keadaan Umum a. Status gizi :
Gemuk
Normal
Berat Badan ...................................... b. Sikap
:
Tenang
Gelisah
Kurus Tinggi Badan
: ...............................................
Menahan nyeri
b. Pemeriksaan Fisik 1) Breathing (B1) a. Bentuk dada: ................................................................................................................. b. Frekuensi nafas : ........................................................................................................... c. Kedalaman nafas : ........................................................................................................ d. Jenis pernafasan :.......................................................................................................... e. Pola nafas : ................................................................................................................... f. Retraksi otot bantu : ..................................................................................................... g. Irama nafas : ................................................................................................................. h. Ekspansi paru : ............................................................................................................. i. Vocal fremitus : ............................................................................................................ j. Nyeri : ........................................................................................................................... k. Batas paru : ................................................................................................................... l. Suara nafas : ................................................................................................................. m. Suara tambahan : .......................................................................................................... n. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... o. Data lain : ..................................................................................................................... ...................................................................................................................................... 2) Blood (B2) a. Ictus cordis : ................................................................................................................. b. Nyeri : ........................................................................................................................... c. Batas jantung : .............................................................................................................. d. Bunyi jantung : ............................................................................................................. e. Suara tambahan : .......................................................................................................... f. Pemeriksaan penunjang : .............................................................................................. Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
...................................................................................................................................... g. Data lain : ..................................................................................................................... ...................................................................................................................................... 3) Brain (B3) a. Kesadaran : ................................................................................................................... b. GCS : ........................................................................................................................... c. Reflek fisiologis : ......................................................................................................... d. Reflek patologis :.......................................................................................................... e. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... f. Data lain : ..................................................................................................................... ...................................................................................................................................... 4) Bladder (B4) a. Kebiasaan miksi : ......................................................................................................... b. Pola miksi : ................................................................................................................... c. Warna urine : ................................................................................................................ d. Jumlah urine : ............................................................................................................... e. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... f. Data lain : ..................................................................................................................... ...................................................................................................................................... 5) Bowel (B5) a. Bentuk abdomen : ......................................................................................................... b. Kebiasaan defekasi : ..................................................................................................... c. Pola defekasi : .............................................................................................................. d. Warna feses : ................................................................................................................ e. Kolostomi : ................................................................................................................... f. Bising usus : ................................................................................................................. g. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... h. Data lain : ..................................................................................................................... ...................................................................................................................................... 6) Bone (B6) a. Kekuatan otot: .............................................................................................................. b. Turgor : ......................................................................................................................... c. Odem : .......................................................................................................................... d. Nyeri : ........................................................................................................................... e. Warna kulit : ................................................................................................................. f. Akral : ........................................................................................................................... Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
g. Sianosis :....................................................................................................................... h. Parese : ......................................................................................................................... i. Alat bantu : ................................................................................................................... j. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... k. Data lain : ..................................................................................................................... .....................................................................................................................................
c. Terapi Medik .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. ..................................................................................................................................................
Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
II. ANALISA DATA NO.
Dep. Keperawatan Kritis
DATA
ETIOLOGI
Prodi Profesi Ners STIKES ICME Jombang
MASALAH
2018/2019
III. DIAGNOSA KEPERAWATAN (SESUAI PRIORITAS) 1. ........................................................................................................................................................ ........................................................................................................................................................ 2. ........................................................................................................................................................ ........................................................................................................................................................ 3. ........................................................................................................................................................ ........................................................................................................................................................ 4. ........................................................................................................................................................ ........................................................................................................................................................ 5. ........................................................................................................................................................ ........................................................................................................................................................
Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
IV. RENCANA TINDAKAN KEPERAWATAN NO.
DIAGNOSA KEPERAWATAN
NOC (SMART) TUJUAN (SMART) :
NIC Label NIC :
Aktifitas Keperawatan : Label NOC :
Indikator : No.
Dep. Keperawatan Kritis
Indikator
1
Indeks 2 3 4
Prodi Profesi Ners STIKES ICME Jombang
5
2018/2019
V. IMPLEMENTASI NO. DX
HARI/ TGL
Dep. Keperawatan Kritis
JAM
TINDAKAN KEPERAWATAN
Prodi Profesi Ners STIKES ICME Jombang
PARAF
2018/2019
VI. EVALUASI NO.
NO. DX
Dep. Keperawatan Kritis
HARI/ TGL
JAM
EVALUASI (SOAP)
Prodi Profesi Ners STIKES ICME Jombang
PARAF
2018/2019
Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
DEPARTEMEN KEPERAWATAN KRITIS
Disusun Oleh: ...............................................
PROGRAM STUDI PROFESI NERS SEKOLAH TINGGI ILMU KESEHATAN INSAN CENDEKIA MEDIKA JOMBANG 2018/2019 Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
PRAKTIK PROFESI NERS PROGRAM STUDI PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN INSAN CENDEKIA MEDIKA JOMBANG Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886 Email: [email protected]
Asuhan Keperawatan pada pasien ................................ Dengan Diagnosa Medis ................................. di Ruang...........................................
I. PENGKAJIAN A. Tanggal Masuk
: ......................................................................................................................
B. Jam masuk
: ......................................................................................................................
C. Tanggal Pengkajian
: ......................................................................................................................
D. Jam Pengkajian
: ......................................................................................................................
E. No.RM
: ......................................................................................................................
F. Identitas 1. Identitas pasien a. Nama
:.............................................................................................................
b. Umur
:.............................................................................................................
c. Jenis kelamin
:.............................................................................................................
d. Agama
:.............................................................................................................
e. Pendidikan
:.............................................................................................................
f. Pekerjaan
:.............................................................................................................
g. Alamat
:.............................................................................................................
h. Status Pernikahan
:.............................................................................................................
2. Penanggung Jawab Pasien a. Nama
:.............................................................................................................
b. Umur
:.............................................................................................................
c. Jenis kelamin
:.............................................................................................................
d. Agama
:.............................................................................................................
e. Pendidikan
:.............................................................................................................
f. Pekerjaan
:.............................................................................................................
g. Alamat
:.............................................................................................................
h. Hub. Dengan PX
:.............................................................................................................
G. Pengkajian 1. Primary Survey a. Airway 1) Posisi kepala : ..................................................................................................................... Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
2) Secret/sputum : ................................................................................................................... 3) Reflek batuk : ..................................................................................................................... 4) Lidah jatuh :........................................................................................................................ 5) Benda asing : ...................................................................................................................... 6) Gigi : ................................................................................................................................... 7) Epistaksis : .......................................................................................................................... 8) Data lain : ........................................................................................................................... b. Breathing 1) Frekuensi nafas : ................................................................................................................. 2) Irama nafas : ....................................................................................................................... 3) Suara nafas : ....................................................................................................................... 4) Kedalaman nafas : .............................................................................................................. 5) Pola nafas : ......................................................................................................................... 6) Jenis pernafasan :................................................................................................................ 7) Suara tambahan : ................................................................................................................ 8) Ekspansi dada : ................................................................................................................... 9) Batuk : ................................................................................................................................ 10) Data lain : ........................................................................................................................... c. Circulation 1) Tekananan darah : .............................................................................................................. 2) Bunyi jantung : ................................................................................................................... 3) Akral : ................................................................................................................................. 4) Sianosis :............................................................................................................................. 5) CRT : .................................................................................................................................. 6) Suhu : .................................................................................................................................. 7) Odem : ................................................................................................................................ 8) Tremor : .............................................................................................................................. 9) Data lain : ........................................................................................................................... d. Disability 1) Kesadaran : ......................................................................................................................... 2) GCS : .................................................................................................................................. 3) Respon nyeri : ..................................................................................................................... 4) Respon bicara : ................................................................................................................... 5) Reflek pupil : ...................................................................................................................... 6) Spasme otot: ....................................................................................................................... 7) Parastesia : .......................................................................................................................... 8) ROM : ................................................................................................................................. 9) Data lain ............................................................................................................................. e. Exposure Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
1) Cedera :............................................................................................................................... 2) Kerusakan jaringan : ........................................................................................................... 3) Dislokasi : ........................................................................................................................... 4) Luka : .................................................................................................................................. 5) Odem : ................................................................................................................................ 6) Data lain : ........................................................................................................................... ............................................................................................................................................
2. Secondary Survey a. Keadaan Umum a. Status gizi :
Gemuk
Normal
Berat Badan ...................................... b. Sikap
:
Tenang
Gelisah
Kurus Tinggi Badan
: ...............................................
Menahan nyeri
b. Pemeriksaan Fisik 1) Breathing (B1) a. Bentuk dada: ................................................................................................................. b. Frekuensi nafas : ........................................................................................................... c. Kedalaman nafas : ........................................................................................................ d. Jenis pernafasan :.......................................................................................................... e. Pola nafas : ................................................................................................................... f. Retraksi otot bantu : ..................................................................................................... g. Irama nafas : ................................................................................................................. h. Ekspansi paru : ............................................................................................................. i. Vocal fremitus : ............................................................................................................ j. Nyeri : ........................................................................................................................... k. Batas paru : ................................................................................................................... l. Suara nafas : ................................................................................................................. m. Suara tambahan : .......................................................................................................... n. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... o. Data lain : ..................................................................................................................... ...................................................................................................................................... 2) Blood (B2) a. Ictus cordis : ................................................................................................................. b. Nyeri : ........................................................................................................................... c. Batas jantung : .............................................................................................................. d. Bunyi jantung : ............................................................................................................. e. Suara tambahan : .......................................................................................................... f. Pemeriksaan penunjang : .............................................................................................. Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
...................................................................................................................................... g. Data lain : ..................................................................................................................... ...................................................................................................................................... 3) Brain (B3) a. Kesadaran : ................................................................................................................... b. GCS : ........................................................................................................................... c. Reflek fisiologis : ......................................................................................................... d. Reflek patologis :.......................................................................................................... e. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... f. Data lain : ..................................................................................................................... ...................................................................................................................................... 4) Bladder (B4) a. Kebiasaan miksi : ......................................................................................................... b. Pola miksi : ................................................................................................................... c. Warna urine : ................................................................................................................ d. Jumlah urine : ............................................................................................................... e. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... f. Data lain : ..................................................................................................................... ...................................................................................................................................... 5) Bowel (B5) a. Bentuk abdomen : ......................................................................................................... b. Kebiasaan defekasi : ..................................................................................................... c. Pola defekasi : .............................................................................................................. d. Warna feses : ................................................................................................................ e. Kolostomi : ................................................................................................................... f. Bising usus : ................................................................................................................. g. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... h. Data lain : ..................................................................................................................... ...................................................................................................................................... 6) Bone (B6) a. Kekuatan otot: .............................................................................................................. b. Turgor : ......................................................................................................................... c. Odem : .......................................................................................................................... d. Nyeri : ........................................................................................................................... e. Warna kulit : ................................................................................................................. f. Akral : ........................................................................................................................... Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
g. Sianosis :....................................................................................................................... h. Parese : ......................................................................................................................... i. Alat bantu : ................................................................................................................... j. Pemeriksaan penunjang : .............................................................................................. ...................................................................................................................................... k. Data lain : ..................................................................................................................... .....................................................................................................................................
c. Terapi Medik .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. ..................................................................................................................................................
Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
II. ANALISA DATA NO.
Dep. Keperawatan Kritis
DATA
ETIOLOGI
Prodi Profesi Ners STIKES ICME Jombang
MASALAH
2018/2019
III. DIAGNOSA KEPERAWATAN (SESUAI PRIORITAS) 1. ........................................................................................................................................................ ........................................................................................................................................................ 2. ........................................................................................................................................................ ........................................................................................................................................................ 3. ........................................................................................................................................................ ........................................................................................................................................................ 4. ........................................................................................................................................................ ........................................................................................................................................................ 5. ........................................................................................................................................................ ........................................................................................................................................................
Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
IV. RENCANA TINDAKAN KEPERAWATAN NO.
DIAGNOSA KEPERAWATAN
NOC (SMART) TUJUAN (SMART) :
NIC Label NIC :
Aktifitas Keperawatan : Label NOC :
Indikator : No.
Dep. Keperawatan Kritis
Indikator
1
Indeks 2 3 4
Prodi Profesi Ners STIKES ICME Jombang
5
2018/2019
V. IMPLEMENTASI NO. DX
HARI/ TGL
Dep. Keperawatan Kritis
JAM
TINDAKAN KEPERAWATAN
Prodi Profesi Ners STIKES ICME Jombang
PARAF
2018/2019
VI. EVALUASI NO.
NO. DX
Dep. Keperawatan Kritis
HARI/ TGL
JAM
EVALUASI (SOAP)
Prodi Profesi Ners STIKES ICME Jombang
PARAF
2018/2019
Dep. Keperawatan Kritis
Prodi Profesi Ners STIKES ICME Jombang
2018/2019
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