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PROGRAM STUDI PENDIDIKAN NERS FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA PENGALAMAN BELAJAR PRAKTIKA



FORMAT PENGKAJIAN KEPERAWATAN KRITIS Tanggal MRS Tanggal Pengkajian Jam Pengkajian Hari rawat ke IDENTITAS 1. Nama Pasien 2. Umur: 3. Suku/ Bangsa 4. Agama 5. Pendidikan 6. Pekerjaan 7. Alamat 8. Sumber Biaya



: : : :



Jam Masuk : No. RM : Diagnosa Masuk :



: : : : : : :



KELUHAN UTAMA 1. Keluhan utama:……………………………………………………………………………………… ……………………………………………………………………………………………………… … RIWAYAT PENYAKIT SEKARANG 1. Riwayat PenyakitSekarang: ………………………………………………………………………………...................................... ………………………………………………………………………………………………………… ….......................................................................................................................................................... ………………………………………………………………………………………………………… ….......................................................................................................................................................... ………………………………………………………………………………………………………… ….......................................................................................................................................................... RIWAYAT PENYAKIT DAHULU 1. 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: - Kapan : …………………… - Jenis operasi : ……………………



ya



tidak



5. Lain-lain: ................................................................................................................................................................ ................................................................................................................................................................. ................................................................................................................................................................ RIWAYAT KESEHATAN KELUARGA Ya tidak - Jenis :…………………........................................................................ -



1



-



Genogram :



PERILAKU YANG MEMPENGARUHI KESEHATAN Perilaku sebelum sakit yang mempengaruhi kesehatan: Alkohol ya tidak keterangan……………………......................................................... Merokok ya tidak keterangan……………………......................................................... Obat ya tidak keterangan…..............................................................……………… Olahraga ya tidak keterangan…..........................................................………………… OBSERVASI DAN PEMERIKSAAN FISIK 1. Tanda tanda vital S: N: T: RR : Kesadaran Compos Mentis Apatis 2.



Somnolen



Masalah Keperawatan :



Sopor



Koma



Sistem Pernafasan (B1) a. RR:................................ b. Keluhan: sesak nyeri waktu nafas orthopnea Batuk produktif tidak produktif Sekret:…….. Konsistensi :...................... Warna:.......... Bau :.................................. c. Penggunaan otot bantu nafas: ........................................................................................................................................................ ....................................................................................................................................................... d. Irama nafas teratur tidak teratur e. Pleural Friction rub:..................................................................................................................... f. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot g. Suara nafas Cracles Ronki Wheezing h. 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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- Jumlah cairan : ...................................................................................................................... - Undulasi :...................................................................................................................... - Tekanan : ...................................................................................................................... j. Tracheostomy: ya tidak ........................................................................................................................................................ ....................................................................................................................................................... k. Lain-lain: ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ 3. Sistem Kardio vaskuler (B2) a. Keluhan nyeri dada: ya tidak Masalah Keperawatan : P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :................................................................... b. Irama jantung: reguler ireguler c. Suara jantung: normal (S1/S2 tunggal) murmur gallop lain-lain..... d. Ictus Cordis: .................................................................................................................................. e. CRT :.............detik f. Akral: hangat kering merah basah pucat panas dingin g. Sikulasi perifer: normal menurun h. JVP :................................. i. CVP :................................. j. CTR :................................. k. ECG & Interpretasinya: ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ l. Lain-lain : ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ 4.



Sistem Persyarafan (B3) a. GCS : .................................................. b. Refleks fisiologis patella triceps c. Refleks patologis babinsky brudzinsky Lain-lain d. Keluhan pusing ya tidak P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :................................................................... e. Pemeriksaan saraf kranial: N1 : normal N2 : normal N3 : normal N4 : normal N5 : normal N6 : normal N7 : normal N8 : normal N9 : normal



tidak tidak tidak tidak tidak tidak tidak tidak tidak



Masalah Keperawatan : biceps kernig



Ket.: …….............................................................. Ket.: …….............................................................. Ket.: …….............................................................. Ket.: …….............................................................. Ket.: …….............................................................. Ket.: …….............................................................. Ket.: …….............................................................. Ket.: …….............................................................. Ket.: ……..............................................................



3



N10 : N11 : N12 :



normal normal normal



tidak tidak tidak



Ket.: …….............................................................. Ket.: …….............................................................. Ket.: ……..............................................................



f. g. h. i. j. k. l. m. n.



Hoffman/Tromer test : Pupil anisokor isokor Diameter: ……/...... Sclera anikterus ikterus Konjunctiva ananemis anemis Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ........................ IVD :................................................ EVD :................................................ ICP :................................................ Lain-lain: ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ....................................................................................................................................................... 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) Masalah Keperawatan a. Kebersihangenetalia: Bersih Kotor b. Sekret: Ada Tidak c. Ulkus: Ada Tidak d. Kebersihan meatus uretra: Bersih Kotor e. Keluhan kencing: Ada Tidak Bila ada, jelaskan: ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ f. Kemampuan berkemih: Spontan Alat bantu, sebutkan: ....................................................................... Jenis :............................................ Ukuran :............................................ Hari ke :............................................ g. Produksi urine : ………….. ml/jam Warna :............…… Bau :......……….. h. Kandung kemih : Membesar ya tidak i. Nyeri tekan ya tidak j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari k. Balance cairan: ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ o. Lain-lain: ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................



6.



Sistem pencernaan (B5) a. TB :............... b. IMT :............... c. LOLA :............... d. Mulut: e. Membran mukosa: f. Tenggorokan: sakit menelan



BB :................................ Interpretasi :................................ bersih lembab



kotor kering



Masalah Keperawatan :



berbau stomatitis



kesulitan menelan



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pembesaran tonsil nyeri tekan g. Abdomen: tegang kembung ascites h. Nyeri tekan: ya tidak i. 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/darah m. Diet: padat lunak cair n. Diet Khusus: ........................................................................................................................................................ .................................................................................................... o. Nafsu makan: baik menurun Frekuensi:.......x/hari p. Porsi makan: habis tidak Keterangan:....................... q. Lain-lain: ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... 7.



Sistem muskuloskeletal (B6) a. Pergerakan sendi: bebas b. Kekuatan otot:



terbatas



c. Kelainan ekstremitas: ya tidak d. Kelainan tulang belakang: ya tidak Frankel: ................................................................................ e. Fraktur: ya tidak - Jenis :................... f. Traksi: ya tidak - Jenis :................... - Beban :................... - Lama pemasangan :................... g. Penggunaan spalk/gips: ya tidak h. Keluhan nyeri: ya tidak P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :................................................................... i. Sirkulasi perifer: .............................................. j. Kompartemen syndrome ya tidak k. Kulit:ikterik sianosis kemerahan hiperpigmentasi l. Turgor baik kurang jelek m. Luka operasi: ada tidak Tanggal operasi :................ Jenis operasi :................ Lokasi :................ Keadaan :................ Drain : ada tidak - Jumlah :................... - Warna :................... - Kondisi area sekitar insersi :................... n. ROM : ................................................



Masalah Keperawatan :



o. Lain-lain:



5



....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... p. q. r. s.



8.



Pitting edema: +/- grade:................ Ekskoriasis: ya tidak Masalah Keperawatan : Urtikaria: ya tidak Lain-lain: ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................



Sistem Endokrin a. Pembesaran tyroid: ya tidak b. Pembesaran kelenjar getah bening: ya tidak c. Hipoglikemia: ya tidak d. Hiperglikemia: ya tidak e. Lain-lain:..................Jelaskan:..................................................



Masalah Keperawatan :



PENGKAJIAN PSIKOSOSIAL f. Persepsi klien terhadap penyakitnya: ............................................................................................................................... ............................................................................................................................... ...............................................................................................................................



Masalah keperawatan :



g. Ekspresi klien terhadap penyakitnya Murung/diam gelisah tegang marah/menangis h. Reaksi saat interaksi kooperatif tidak kooperatif curiga i. Gangguan konsep diri: ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... j. Lain-lain: ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... PERSONAL HYGIENE & KEBIASAAN



Masalah Keperawatan :



Jelaskan



PENGKAJIAN SPIRITUAL a. Kebiasaan beribadah - Sebelum sakit - Selama sakit



sering sering



kadang- kadang kadang- kadang



tidak pernah tidak pernah



Masalah Keperawatan :



b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah: ............................................................................................................................... ............................................................................................................................... ...............................................................................................................................



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PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)



TERAPI



DATA TAMBAHAN LAIN :



Surabaya, ……………..20...



(………………………)



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PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA



ANALISIS DATA TANGGAL



DATA



ETIOLOGI



MASALAH



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PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA



DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN



TANGGAL: ................................. 1. 2. 3. 4. 5. 6.



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RENCANA INTERVENSI HARI/ TANGGAL



WAKTU



DIAGNOSA KEPERAWATAN (Tujuan, Kriteria Hasil)



INTERVENSI



RASIONAL



10



IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari/Tgl/Shift



No. DK



Jam



Implementasi



Paraf



Jam



Evaluasi (SOAP)



Paraf



11



12