FORMAT PENGKAJIAN ICU TEMPELKAN STIKER PASIEN DISINI
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FORMATPENGKAJIANICU TEMPELKANSTIKERPASIENDISINI DISABILITY CIRCULATION BREATHING AIRWAY DIAGNOSAMEDIS Pasiendatangdari IGD KamarOperasi Bangsal___________ ______________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Jalannafas Ukuran:___________ TanpaAlat OPA ETT/TT Ukuran: Kedalaman:____________________ Sputum Warna:________________________ TidakProduktif Produktif Konsistensi:____________________ Volume:___________cc/______jam Pernafasan Spontan Dibantualat__________ Aliran:________lpm FiO2:__________% RR:_____kalipermenit SpO2:__________% Pergerakan Suaranafas Simetris dada Asimetris Deviasi Tidakada Trakea Ada:__________ WaterSeal Tidakada Drainage TerpasangWSD________________ Volume:____________________cc AnalisaGas pH______________________ Darah PaCO2______________________ HCO3______________________ BE______________________ PaO2______________________ ______________________ Nadi:__________kalipermenit KekuatanNadi 0 +1 +2 +3 +4 o Suhu:__________ C Waktupengisiankapiler(WPK):__________detik TekananDarah:____/____mmHg(MAP:__________mmHg) Elektrokardiografi:______________________________________________________________________ ______________________________________________________________________ IVLine TidakterpasangIVLine TerpasangIVLine Posisi_________________________________ Tanggaldipasang_______________________ UrineOutput Spontan Terpasangalatbantu__________ Volume:____________________cc RoThoraks Tanggalpemeriksaan:_____________________________________________________ Interprestasi:____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ LevelKesadaran: CM Somnolen Apatis Soporus Koma UkuranPupil:Kanan___mmKiri___mm Responcahaya:___/___ GCS E__M__V___ SkalaNyeri:_________________ FormatpengkajianICUdenganpendekatanABCDEdibuatdandimodifikasiolehEriYanuarAkhmadB.S.,S.Kep.,Ns.,M.N.Sc.(I.C)(c)2016 MASALAHKEPERAWATAN LAIN-LAIN EXPOSURE Konjungtiva TidakAnemis Anemis Mukosamulut Lembab Kering _______ Abdomen BisingUsus Lunak Distensi Asites Tidakterdengar Massa Striae _________ Terdengar_______x/menit Kolostomi _________ Nutrisi Oral Parenteral TPN ______________ Diit______________________________________ TurgorKulit________________________________ IntegritasKulit______________________________ SkalaBraden_______________________________ PosisiLuka Alatinvasif#___ Alatinvasif#___ Jenisalat:________________________________ Jenisalat:________________________________ Letakpemasangan:________________________ Letakpemasangan:________________________ Tanggalterpasang:________________________ Tanggalterpasang:________________________ Alatinvasif#___ Alatinvasif#___ Jenisalat:________________________________ Jenisalat:________________________________ Letakpemasangan:________________________ Letakpemasangan:________________________ Tanggalterpasang:________________________ Tanggalterpasang:________________________ Alatinvasif#___ Alatinvasif#___ Jenisalat:________________________________ Jenisalat:________________________________ Letakpemasangan:________________________ Letakpemasangan:________________________ Tanggalterpasang:________________________ Tanggalterpasang:________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Bersihanjalannafastidakefektif Polanafastidakefektif Gangguanpertukarangas Penurunancurahjantung Kerusakanventilasispontan Nyeriakut Resikosyok Defisitvolumecairan Resikoinfeksi _____________________________ _____________________________ Yogyakarta,____________________ Perawatyangmengkaji (.........................................) FormatpengkajianICUdenganpendekatanABCDEdibuatdandimodifikasiolehEriYanuarAkhmadB.S.,S.Kep.,Ns.,M.N.Sc.(I.C)(c)2016