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PROGRAM STUDI PENDIDIKAN NERSFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
PENGALAMAN BELAJAR PRAKTIKA
FORMAT PENGKAJIAN KEPERAWATAN KRITIS
Tanggal MRS : Jam Masuk :Tanggal Pengkajian : No. RM :Jam Pengkajian : Diagnosa Masuk :Hari rawat ke :
IDENTITAS1. Nama Pasien :2. Umur:3. Suku/ Bangsa :4. Agama :5. Pendidikan :6. Pekerjaan :7. Alamat :8. Sumber Biaya :
KELUHAN UTAMA1. Keluhan utama:………………………………………………………………………………………
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RIWAYAT PENYAKIT SEKARANG1. Riwayat PenyakitSekarang:
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RIWAYAT PENYAKIT DAHULU1. Pernah dirawat : ya tidak kapan :…… diagnosa :…………2. Riwayat penyakit kronik dan menular ya tidak jenis……………………
Riwayat kontrol : .............................Riwayat penggunaan obat :..............
3. Riwayat alergi:Obat ya tidak jenis……………………Makanan ya tidak jenis……………………Lain-lain ya tidak jenis……………………
4. Riwayat operasi: ya tidak- Kapan : ……………………- Jenis operasi : ……………………
5. Lain-lain:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGAYa tidak
- Jenis :…………………........................................................................-
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- Genogram :
PERILAKU YANG MEMPENGARUHI KESEHATANPerilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidakketerangan…………………….........................................................Merokok ya tidakketerangan…………………….........................................................Obat ya tidakketerangan…..............................................................………………Olahraga ya tidakketerangan…..........................................................…………………
OBSERVASI DAN PEMERIKSAAN FISIK1. Tanda tanda vital
S : N : T : RR :Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
2. Sistem Pernafasan (B1)a. RR:................................b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktifSekret:…….. Konsistensi :......................Warna:.......... Bau :..................................
c. Penggunaan otot bantu nafas:...............................................................................................................................................................................................................................................................................................................
d. Irama nafas teratur tidak terature. Pleural Friction rub:.....................................................................................................................f. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biotg. Suara nafas Cracles Ronki Wheezingh. Alat bantu napas ya tidak
Jenis................................................ Flow..............lpm
Ventitalor Mode : FiO2 : PEEP : SaO2 : Vol. Tidal: I:E Ratio: Lain-lain :
i. Penggunaan WSD:- Jenis : ......................................................................................................................
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Masalah Keperawatan :
- Jumlah cairan : ......................................................................................................................- Undulasi :......................................................................................................................- Tekanan : ......................................................................................................................
j. Tracheostomy: ya tidak...............................................................................................................................................................................................................................................................................................................
k. Lain-lain:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Sistem Kardio vaskuler (B2)a. Keluhan nyeri dada: ya tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
b. Irama jantung: reguler iregulerc. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....d. Ictus Cordis: ..................................................................................................................................e. CRT :.............detikf. Akral: hangat kering merah basah pucat
panas dinging. Sikulasi perifer: normal menurunh. JVP :.................................i. CVP :.................................j. CTR :.................................k. ECG & Interpretasinya:
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........................................................................................................................................................l. Lain-lain :
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4. Sistem Persyarafan (B3)a. GCS : ..................................................b. Refleks fisiologis patella triceps bicepsc. Refleks patologis babinsky brudzinsky kernig
Lain-laind. Keluhan pusing ya tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
e. Pemeriksaan saraf kranial:N1 : normal tidak Ket.: ……..............................................................N2 : normal tidak Ket.: ……..............................................................N3 : normal tidak Ket.: ……..............................................................N4 : normal tidak Ket.: ……..............................................................N5 : normal tidak Ket.: ……..............................................................N6 : normal tidak Ket.: ……..............................................................N7 : normal tidak Ket.: ……..............................................................N8 : normal tidak Ket.: ……..............................................................N9 : normal tidak Ket.: ……..............................................................
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Masalah Keperawatan :
Masalah Keperawatan :
N10 : normal tidak Ket.: ……..............................................................N11 : normal tidak Ket.: ……..............................................................N12 : normal tidak Ket.: ……..............................................................
f. Hoffman/Tromer test : g. Pupil anisokor isokor Diameter: ……/......h. Sclera anikterus ikterusi. Konjunctiva ananemis anemisj. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ........................k. IVD :................................................l. EVD :................................................m. ICP :................................................n. Lain-lain:
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....................................................................................................................................................... o. Tanda-Tanda PTIK: p. Gangguan pendengaran: Ada Tidak , Jelaskan: q. Gangguan penglihatan : Ada Tidak, Jelaskan: r. Gangguan Penciuman ; Ada Tidak, Jelaskan
5. Sistem perkemihan (B4)a. Kebersihangenetalia: Bersih Kotorb. Sekret: Ada Tidakc. Ulkus: Ada Tidakd. Kebersihan meatus uretra: Bersih Kotore. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
f. Kemampuan berkemih:Spontan Alat bantu, sebutkan: .......................................................................Jenis :............................................Ukuran :............................................Hari ke :............................................
g. Produksi urine : ………….. ml/jamWarna :............……Bau :......………..
h. Kandung kemih : Membesar ya tidaki. Nyeri tekan ya tidakj. Intake cairan oral : ……… cc/hari parenteral : ……… cc/harik. Balance cairan:
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........................................................................................................................................................o. Lain-lain:
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6. Sistem pencernaan (B5)a. TB :............... BB :................................b. IMT :............... Interpretasi :................................c. LOLA :...............
d. Mulut: bersih kotor berbaue. Membran mukosa: lembab kering stomatitisf. Tenggorokan:
sakit menelan kesulitan menelan
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Masalah Keperawatan
Masalah Keperawatan :
pembesaran tonsil nyeri tekang. Abdomen: tegang kembung ascitesh. Nyeri tekan: ya tidaki. Luka operasi: ada tidak
Tanggal operasi :................Jenis operasi :................Lokasi :................ Keadaan :................Drain : ada tidak - Jumlah :...................- Warna :...................- Kondisi area sekitar insersi :...................
j. Peristaltik:.............. x/menit k. BAB: ......................x/hari Terakhir tanggal : ..............l. Konsistensi: keras lunak cair lendir/darahm. Diet: padat lunak cairn. Diet Khusus:
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....................................................................................................o. Nafsu makan: baik menurun Frekuensi:.......x/harip. Porsi makan: habis tidak Keterangan:.......................q. Lain-lain:
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7. Sistem muskuloskeletal (B6)a. Pergerakan sendi: bebas terbatasb. Kekuatan otot:
c. Kelainan ekstremitas: ya tidakd. Kelainan tulang belakang: ya tidak
Frankel: ................................................................................e. Fraktur: ya tidak
- Jenis :...................f. Traksi: ya tidak
- Jenis :...................- Beban :...................- Lama pemasangan :...................
g. Penggunaan spalk/gips: ya tidakh. Keluhan nyeri: ya tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
i. Sirkulasi perifer: ..............................................j. Kompartemen syndrome ya tidakk. Kulit:ikterik sianosis kemerahan hiperpigmentasil. Turgor baik kurang jelekm. Luka operasi: ada tidak
Tanggal operasi :................Jenis operasi :................Lokasi :................ Keadaan :................Drain : ada tidak - Jumlah :...................- Warna :...................- Kondisi area sekitar insersi :...................
n. ROM : ................................................
o. Lain-lain:
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Masalah Keperawatan :
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p. Pitting edema: +/- grade:................q. Ekskoriasis: ya tidakr. Urtikaria: ya tidaks. Lain-lain:
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8. Sistem Endokrina. Pembesaran tyroid: ya tidakb. Pembesaran kelenjar getah bening: ya tidakc. Hipoglikemia: ya tidakd. Hiperglikemia: ya tidake. Lain-lain:..................Jelaskan:..................................................
PENGKAJIAN PSIKOSOSIALf. Persepsi klien terhadap penyakitnya:
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g. Ekspresi klien terhadap penyakitnya Murung/diam gelisah tegang marah/menangish. Reaksi saat interaksi kooperatif tidak kooperatif curigai. Gangguan konsep diri:
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j. Lain-lain:.............................................................................................................................................................................................................................................................................................................................................................................................
PERSONAL HYGIENE & KEBIASAAN
Jelaskan
PENGKAJIAN SPIRITUALa. Kebiasaan beribadah
- Sebelum sakit sering kadang- kadang tidak pernah- Selama sakit sering kadang- kadang tidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:.............................................................................................................................................................................................................................................................................................................................................................................................
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Masalah Keperawatan :
Masalah keperawatan :
Masalah Keperawatan :
Masalah Keperawatan :
Masalah Keperawatan :
PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)
TERAPI
DATA TAMBAHAN LAIN :
Surabaya, ……………..20...
(………………………)
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PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
ANALISIS DATA
TANGGAL DATA ETIOLOGI MASALAH
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PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN
TANGGAL: .................................
1.
2.
3.
4.
5.
6.
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RENCANA INTERVENSI
HARI/TANGGAL
WAKTUDIAGNOSA KEPERAWATAN
(Tujuan, Kriteria Hasil)INTERVENSI RASIONAL
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IMPLEMENTASI DAN EVALUASI KEPERAWATAN
Hari/Tgl/Shift No. DK Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
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