ASUHAN KEPERAWATAN PADA Tn/Ny/Nn/An……...

DENGAN ………………………………………….

I. Identitas Pasien
Nama : …………………………………………………………………..
Usia : …………………………………………………………………..
Jenis kelamin : …………………………………………………………………..
Alamat : …………………………………………………………………..
No. Reg : …………………………………………………………………..
Diagnosa medis : ……………………………………………………………………
Tanggal MRS : ……………………………………………………………………
Jam MRS : ……………………………………………………………………
Tanggal pengkajian : …………………………………………………………………..
Jam pengkajian : …………………………………………………………………..

II. Data Subyektif

 Keluhan utama
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 Provocative
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 Quality
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 Regio/Radiation
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 Severe-severity
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  Skala
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 Time
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 Mekanisme kejadian/ MIVT (mechanism of injury, injury sustained, vital signs,
treatments)
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M ……………………………………………………………………………………………………
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L ……………………………………………………………………………………………………
E ……………………………………………………………………………………………………

 Riwayat penyakit dahulu

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III. Data Obyektif
 Airway
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 Breathing
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 Circulation
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 Disability
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 Exposure
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 Full Vital Signs – Five intervention – Family presence
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 Give Comfort measures
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 Head to Toe Examination

 Keadaan Umum
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 Kepala dan Wajah
- Kepala
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- Mata
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- Telinga
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- Hidung
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- Mulut
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- Leher
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  Dada
Jantung :

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Paru :
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 Perut dan Pinggang

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 Pelvis dan Perineum
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 Ekstremitas
Atas
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Bawah
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 Inspect posterior surface
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IV. Pemeriksaan Penunjang

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  Lab darah :
 Lab urin :
 ECG :
 Rontgen :
 USG :
 CT Scan :
 BGA :
 Pa CO2 : ……………………………………………………….
 Pa O2 : ……………………………………………………….
 Sa O2 : ……………………………………………………….
 pH : ……………………………………………………….
 HCO3 : ……………………………………………………….

V. Therapi :
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Tindakan Resusitasi
No Tgl/Jam Tindakan Resusitasi Keterangan

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VI. Analisa Data
No Tanda Etiologi Problem
1

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 3

VII. Prioritas Dx Keperawatan

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 No Prioritas Diagnosa Keperawatan
1

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VIII. Intervensi Keperawatan
Dx Tgl/ Tujuan Intervensi Keperawatan & Ttd
Kep Jam Rasional
1

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 3

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IX. Implementasi

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 Dx Tgl/
Implementasi Ttd
Kep Jam

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 X. Lembar Observasi (khusus Px P1)
NO. TGL JAM TD NADI RR S GCS SaO2 INPUT OUTPUT KETERA
NGAN
CAIRAN URIN

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XI. Evaluasi Akhir
Dx Tgl/
Evaluasi Ttd
Kep Jam
1 S:

O:

A:

P:

2 S:

O:

A:

P:

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 3 S:

O:

A:

P:

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XII. Discharge Planing
Format Discharge Planning (Pulang/Pindah Ruangan)
 Pasien mengatakan sesaknya sudah berkurang
S
Pasien mengatakan sekarang sudah bisa bernafas kembali
 RR: 18x/menit, nadi : 92x/menit, tensi 120/80 mmHg, suhu: 37,2°C
 Sa O2: 85%, CRT: 3”
 Pernafasan cuping hidung
 Wheezing berkuang
O  Penggunaan otot bantu pernafasan tidak ada
 Pasien bisa melakukan batuk efektif
 Sianosis pada mukosa bibir berkurang
 Ujung hidung dan telinga lembab
Akral mulai hangat

A Masalah sebagian teratasi

Pertahankan intervensi

 Kaji fungsi pernapasan: bunyi napas, kecepatan, irama, kedalaman dan pengunaan
otot aksesoris dan tanda-tanda vital lainnya
 Catat kemampuan untuk mengeluarkan mukus/ batuk efektif, catat karakter jumlah
sputum
 Perhatikan pergerakan dinding dada, amati kesimetrisan, penggunaan otot bantu
I
pernafasan, serta retraksi otot supraklavikular dan interkosta
 Observasi terhadap sianosis terutama membrane mukosa mulut, hidung, ujung telinga
dan ujung daerah ekstremitas
 Pantau status mental (tidur, apatis, tidak perhatian, gelisah, bingung dan somnolen)
 Pertahankan aliran oksigen dengan menggunakan masker non rebreathing.
Masalah sebagian teratasi

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 Nama pasien Tn/Ny/Nn/An (P/L) masuk rumah sakit pada tanggal…………………….,
jam………….WIB dengan diagnosa medis…………………………….telah diberikan
tindakan di atas. Untuk itu perlu perawatan lanjutan di………………………kunjungan
rutin ke……………………….mulai tanggal………………………..

Terapi obat yang diberikan.:

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Anjuran :
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Malang, ………………………….
ttd

(Ns. Karina Aulia, S.Kep )

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