8/11/2019 Dokumentasi Asuhan Keperawatan Kritis

DOKUMENTASI ASUHAN
KEPERAWATAN KRITIS
Nengah Runiari, M.Kep, Sp.Mat

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8/11/2019 Dokumentasi Asuhan Keperawatan Kritis

 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 of
position

 Is hemodynamically unstable and may require

frequent monitoring of vital signs, respiratory
assessments, pressure monitoring, patent IV
medications


May be intubated, may need endotracheal
suctioning, ABG assessment, ventilator
management

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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
patients condition warrants as

 Nurses notes

ECG rhythm strips and hemodynamic

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 May be NPO because of being intubated,

having nasogastric suction, postoperative
or digestive tract problems, or inability to
take oral nutrition.

 May need frequent monitoring /

interpretation
 ABGs, clottingofstudies,
laboratory valuesblood
complete such as
caount (CBC), urinalysis and electrlytes

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 Will be on strict intake and output may

have an indwelling catheter and will need
frequent urine specific gravity readings


May have several painful incisions or
dressing that require IV analgesia and
time consuming dressing changes.

 May be neurologically unstable or may

have neurologic deficits.

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INITIAL ADMISSION/
BASELINE DATA LIST
 RESPIRATORY SYSTEM :airway integrity,
airway adjuncts, respirations, ventilator, cough-
effort, secretions, central cyanosis, subjective
complaint, color
 Cardiovascular : Blood pressure, hearth rate,
peripheral pulses, skin color, turgor, temperatur,
CRT,Swan –Ganz

Neurologic : level function,
orientation,Motor of conciousness,
movements, muscle
tones

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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 psychologic
stressors in critical care environment :
a. Lack of control results from physical disability,
surgery, trauma, intubation
b. Feelings of powerlessness (actual or potential) due to
illness, depression, change in mental status, lack of
control over environment

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c. Depersonalization, possibly from being labeled

according to one’s disease, cubicle number,
chronic characteristics.
d. Crowding, lack of space due to design of
environment; presence of many doctor,
technicians; frequent interruptions

3.and
Interventions are directed
life maintenance duringtoward lifethe
the time saving
patient’s condition is unstable 

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4. Individualized nursing care plans are written and

revised as patient’s health status improves or
deteriorates.

5. Evaluation statements are directed toward the

patient’s condition, expected or unexpected
outcomes, problem resolution, identification of

new problems
success based
or failure upon reassessment,
of other plans and and
interventions

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