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    .

    ASUHAN KEPERAWATAN KRITIS

    Nama :
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    Usia :
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    Alamat :
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    No. Register :
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    KriteriaKlien : ……………………………………………………………....
    Tanggal MRS : …………………………………………………………........
    TanggalPengkajian : ……………………………………………………………...

    I. PENGKAJIAN
    1. RiwayatPenyakit
    a. Riwayat Penyakit Sekarang
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    b. Riwayat Penyakit Dahulu


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    c. Riwayat Penyakit Keluarga


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    d. Diagnosa Medis
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    2. Secondary Survey
    a. B1 (Breath)
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    b. B2 (Blood)
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    c. B3 (Brain)
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    d. B4 (Bowel)
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    e. B5 (Bladder)
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    f. B6 (Bone)
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    3. Pemeriksaan Penunjang
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    4. Terapi Farmakologi
    Nama Nama Dosis dan Indikasi Kontra Efek Tanggung
    Dagang Generik Rute indikasi Samping Jawab
    Pemberian Perawat

    Banjarmasin, 2018

    (…………………………………….)
    II. ANALISA DATA
    No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)
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    III. PRIORITAS DIAGNOSA KEPERAWATAN
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    IV. RENCANA KEPERAWATAN

    No. Diagnosa Keperawatan Tujuan dan Kriteria Hasil Intervensi


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    V. IMPLEMENTASI
    No. Tanggal/Jam TindakanKeperawatan Paraf
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    VI. CATATAN OBSERVASI
    No. Diagnosa Keperawatan Tanggal/Jam Catatan Observasi (SOAPIE)
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    VII. EVALUASI
    No. Diagnosa Keperawatan Tanggal/Jam Evaluasi (SOAP)
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    PEMERIKSAAN PENUNJANG

    Jika Ada Pemeriksaan Baru Setelah Pengkajian


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