DOKUMENTASI ASUHAN

KEPERAWATAN KRITIS
Nengah Runiari, M.Kep, Sp.Mat
ASUHAN KEPERAWATAN KRITIS
Nursing care intensity
A high-technology environment
Complex patient problems
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
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
Equipment : O2, ventilator setting
Lab data/diagnostics
Physical assessments/observation as
patients condition warrants
Nurses notes
ECG rhythm strips and hemodynamic
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 of laboratory values such as
ABGs, clotting studies, complete blood
caount (CBC), urinalysis and electrlytes

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.
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 of conciousness,
orientation,Motor function, movements, muscle
tones

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

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
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 saving
and life maintenance during the time the
patients condition is unstable

4. Individualized nursing care plans are written and
revised as patients health status improves or
deteriorates.

5. Evaluation statements are directed toward the
patients condition, expected or unexpected
outcomes, problem resolution, identification of
new problems based upon reassessment, and
success or failure of other plans and
interventions