Dokumentasi Asuhan Keperawatan Kritis

8/11/2019 Dokumentasi Asuhan Keperawatan Kritis

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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

Dokumentasi Asuhan Keperawatan Kritis

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