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Format Laporan Kasus Kelolaan Icu
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LAPORAN KASUS KELOLAAN
ASUHAN KEPERAWATAN PADA KEGAWATDARURATAN
SISTEM.......................................PADA......................
DENGAN...................................................
DI RUANG ICU RSUD TUGUREJO SEMARANG
A. Pengkajian
1. Identitas
Identitas klien
Nama klien :
Umur :
Jenis kelamin :
Alamat :
Tanggal masuk :
Tanggal pengakajian :
Jam :
Diagnosa medis :
2. Keluhan utama :
3. Pengkajian Fokus
a. Pengkajian Primer1) Airway
2) Breathing
1
3) Circulasi
4) Disability
5) Eksposure
b. Pengkajian Sekunder
1) Riwayat Penyakit Sekarang
2
2) Riwayat Penyakit Dahulu
3) Riwayat Penyakit Keluarga
3
4. Pemeriksaan Fisik
1) Kepala dan muka
Inspeksi: .........................................................................................................................
...........................................................................................................................
Palpasi :
.........................................................................................................................................
...........................................................................................................
2) Mata dan telinga
Inspeksi :
.........................................................................................................................................
...........................................................................................................
Palpasi : ..........................................................................................................................
..........................................................................................................................
3) Hidung
Inspeksi :
..........................................................................................................................
Palpasi :
..........................................................................................................................
4) Mulut dan tenggorokan
Inspeksi : ........................................................................................................................
............................................................................................................................
Palpasi : ..........................................................................................................................
..........................................................................................................................
5) Kulit
Inspeksi: .........................................................................................................................
...........................................................................................................................
Palpasi : ...........................................................................................................
4
6) Dada/Jantung/paru
Inspeksi dada :
.....................................................................................................................
...............................................................................................................................
Palpasi paru :
.........................................................................................
.........................................................................................................................................
..................
Auskultasi paru : ..............................................................................................
Perkusi paru : ...................................................................................................
Auskltasi jantung :
.........................................................................................................................................
...........................................................................................................
Palpasi jantung : ..............................................................................................
Perkusi jantung : ..............................................................................................
7) Abdomen
Inspeksi :
..............................................................................................................................
......................................................................................................................
Askultasi : ........................................................................................................
Palpasi :
..............................................................................................................................
......................................................................................................................
Perkusi : ...........................................................................................................
8) Genetalia
5
.........................................................................................................................................
.........................................................................................................................................
...........................................................................................
9) Ekstremitas
Inspeksi :
..............................................................................................................................
......................................................................................................................
Palpasi : ............................................................................................................
10) Parameter umum
Kesadaran :..................
Kesadaran :..................
Vital sign
Tekannan Darah : ............... mmHg
Map :................
Rr : .........x/menit
Hr : .........x/menit
SPO2 : ............
Suhu : .........oC
6
5. Prosedur diagnostik dan laboratorium
Prosedur diagnostik dan laboratorium
Tgl pemeriksaan
Indikasi dan tujuan Hasil Nilai normal Analisa
7
Tanggung Jawab Perawat :
Sebelum :
Sesudah :
Setelah :
8
B. Analisa data
DATA MASALAH ETIOLOGI
9
10
11
1. Diangnosa Keperawatan1. ...................................................................................................................................................................................
2. ...................................................................................................................................................................................
3. ...................................................................................................................................................................................
4. ...................................................................................................................................................................................
5. ...................................................................................................................................................................................
12
C. Nursing Care Plan
No Hari/
Tanggal
Tujuan dan Kreteria Hasil Intervensi Keperawatan Rasional Paraf
13
14
15
D. IMPLEMENTASI
1. Medical Management
IVF, O2 terapi
Medical
managemen
t
Tanggal
Terapi
Penjelasan secara umum Indikasi dan
tujuan
Respon
16
2. Obat – obatan
Nama
obat
Tanggal
Terapi
Cara, dosis,
frekuensi
Cara kerja obat, fungsi
dan klasifikasi
Respon
17
18
3. Diet
Jenis
diit
Tangga
l Terapi
Penjelasan umum Indikasi dan
Tujuan
Makanan
Spesifik
Respon
19
4. Aktifitas dan Latihan
Jenis
aktivitas
dan latihan
Tanggal
Terapi
Penjelasan umum Indikasi dan Tujuan Respon
Klien
20
D. IMPLEMENTASI KEPERAWATAN
Tanggal/
Hari jam
No. Dx Tindakan Keperawatan Respon Klien Paraf
21
22
23
24
25
26
E. EVALUASI
Hari/Tanggal No. Dx Evaluasi Respon Klien Paraf
27
28
F. KESIMPULAN
29