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DOKUMENTASI ASUHAN
KEPERAWATAN KRITISNengah Runiari, M.Kep, Sp.Mat
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ASUHAN KEPERAWATAN KRITIS
Nursing care intensity
A high-technology environment Complex patient problems
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Typical critical care patient
May require total care, including change ofposition
Is hemodynamically unstable and may requirefrequent monitoring of vital signs, respiratoryassessments, pressure monitoring, patent IVmedications
May be intubated, may need endotrachealsuctioning, ABG assessment, ventilatormanagement
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FLOW SHEETS FOR RECORDING
BEDSIDE MONITORING
Vital sign, temperature
Intake-oral/IV therapies-TPN, IVs, blood
products
Vasopressor /antidysrithmic medication
administration
Output-tubes, drains, urine Clinical data : CVP arterial blood gases
Procedurs : ECG, chest x rays
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Equipment : O2, ventilator setting
Lab data/diagnostics
Physical assessments/observation aspatients condition warrants
Nurses notes
ECG rhythm strips and hemodynamic
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May be NPO because of being intubated,having nasogastric suction, postoperativeor digestive tract problems, or inability to
take oral nutrition.
May need frequent monitoring /
interpretation of laboratory values such asABGs, clotting studies, complete bloodcaount (CBC), urinalysis and electrlytes
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Will be on strict intake and output may
have an indwelling catheter and will needfrequent urine specific gravity readings
May have several painful incisions ordressing that require IV analgesia andtime consuming dressing changes.
May be neurologically unstable or mayhave neurologic deficits.
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INITIAL ADMISSION/
BASELINE DATA LIST
RESPIRATORY SYSTEM :airway integrity,airway adjuncts, respirations, ventilator, cough-effort, secretions, central cyanosis, subjectivecomplaint, color
Cardiovascular : Blood pressure, hearth rate,peripheral pulses, skin color, turgor, temperatur,CRT,SwanGanz
Neurologic : level of conciousness,orientation,Motor function, movements, muscletones
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FUNCTIONAL ASSESSMENT OF
BODY ORGANS
Renal system : urine, skin, acid base balance,
admission weight
Gastrointestinal : abdominal assessment, stools,
nasogastric, nutrition Endocrine : perhistory, perspesific disorder
Hematologic : color of mucous membranes, nail
beds, signs of bleeding, lesions, ulcerations Musculoskeletal : deformities, movements,
muscli tones
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CRITICAL CARE DOCUMENTATION
1. Priority assessment are directed toward
respiratory, cardiovascular and neurologic
system functions
2. Assessment data related to psychologicstressors in critical care environment :
a. Lack of control results from physical disability,
surgery, trauma, intubation
b. Feelings of powerlessness (actual or potential) due toillness, depression, change in mental status, lack of
control over environment
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c. Depersonalization, possibly from being labeled
according to ones disease, cubicle number,
chronic characteristics.
d. Crowding, lack of space due to design of
environment; presence of many doctor,
technicians; frequent interruptions
3. Interventions are directed toward life savingand life maintenance during the time the
patients condition is unstable
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4. Individualized nursing care plans are written andrevised as patients health status improves ordeteriorates.
5. Evaluation statements are directed toward thepatients condition, expected or unexpectedoutcomes, problem resolution, identification of
new problems based upon reassessment, andsuccess or failure of other plans andinterventions
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