Asuhan Keperawatan Profesi KGD

Nama Mahasiswa

Kasus/Diagnosa Medis :
Jenis Kasus : Trauma / Non
Trauma/ICU
Ruangan :
Kasus ke :

CATATAN KOREKSI PEMBIMBING

KOREKSI I KOREKSI II

(………………………………………………………..………...………) (……………………..…………...……………………………………...)
 FORMAT ASUHAN KEPERAWATAN GAWAT
DARURAT (Intensive Care Unit)

Tanggal Rawat : ……………………….. No.Medrec : ………………………..

Tanggal Pengkajian : ……………………….. Diagnosa Medis : ………………………..

A. IDENTITAS KLIEN
Nama : ………………………..

Umur : ………………………..

Jenis kelamin : ………………………..

Pendidikan : ………………………..

Pekerjaan : ………………………..

Agama : ………………………..

Status Marital : ………………………..

Suku / Bangsa : ………………………..

Alamat :……………………………………………………………………………………………………………………..………………………………………

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B. IDENTITAS PENANGGUNG JAWAB

Nama : ………………………..

Umur : ………………………..

Jenis Kelamin : ………………………..

Pekerjaan : ………………………..

Alamat : …………………………………………………………………………………………………………………………………………………………….

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Hubungan Dengan Klien :.......................................................................................................................................................………………………………..

C. RIWAYAT KESEHATAN

1. Alasan Masuk ICU

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2. Keluhan Utama
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3. Riwayat Kesehatan Sekarang

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4. Riwayat Kesehatan Dahulu

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5. Riwayat Kesehatan Keluarga

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D. KEMAMPUAN PERAWATAN DIRI

1. Feeding  Mandiri  Dibantu  Total Care

2. Toileting  Mandiri  Dibantu  Total Care
3. Bathing  Mandiri  Dibantu  Total Care
4. Grooming  Mandiri  Dibantu  Total Care

E. SCORE SKALA BRADEN : …………………………………………….

INTERPRESTASI HASIL :……………………………………………

F. PEMERIKSAAN FISIK
1. Kesadaran : ……………………..
2. Tanda Vital
a. Suhu :……………………..
b. Tekanan Darah :……………………..
c. Nadi :……………………..
d. Respirasi : ……………………..
e. Saturasi O2 : ……………………..
 Asuhan Keperawatan Profesi KGD 2017-2018

3. Data pengkajian fisik fokus

4. Hasil Pemeriksaan Diagnostik

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5. Program Terapi:
a. Nutrisi :
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Format Asuhan Keperawatan

 Asuhan Keperawatan Profesi KGD 2017-2018

b. Cairan :
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c. Obat obatan :
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6. Pennggunaan alat bantu:
 Bedside Monitor
 Infusion Pump (jenis cairan……………….., kecepatan aliran……………. Penambahan obat
………………………..……………, dosis obata………………….)
 Syringe Pump (jenis obat…………………………., Kecepatan aliran…………………….)
 Ventilator (Setting:......................................................................................................................)
 ………………………….

DATA PENGETAHUAN
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DATA PSIKOSOSIAL SPIRITUAL

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Format Asuhan Keperawatan

 Asuhan Keperawatan Profesi KGD 2017-2018

ANALISA DATA

DATA ETIOLOGI DIAGNOSA KEPERAWATAN

Diagnosa Keperawatan berdasarkan prioritas:

1. …………………………………………………………………………………………………………………………………………………………
2. …………………………………………………………………………………………………………………………………………………………

Format Asuhan Keperawatan

NURSING CARE PLAN

Nama Pasien:……………………………….. Umur :……………..tahun No Medrek:…………………………….. Diagnosa Medis:………………………….

TUJUAN DAN KRITERIA INTERVENSI AKTIVITAS

DX. KEPERAWATAN
(NOC) (NIC DOMAIN) (NIC)
IMPLEMENTASI DAN EVALUASI

Nama Pasien : Usia:

No Medrek : Diagnosa Medis:

NO. DX TANGGAL IMPLEMENTASI EVALUASI PARAF

 CATATAN PERKEMBANGAN ASUHAN KEPERAWATAN

Nama Pasien : Usia:

No Medrek : Diagnosa Medis:

Tanggal No Diagnosa Catatan Perkembangan Paraf

( SOAPIE )
 Asuhan Keperawatan Profesi KGD 2017-2018

LAMPIRAN LEMBAR MONITORING ICU

*Lampirkan Lembar observasi Monitoring ICU

Format Asuhan Keperawatan