format pengkajian kritis

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PROGRAM STUDI PENDIDIKAN NERS FAKULTAS 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 : IDENTITAS 1. Nama Pasien : 2. Umur : 3. Suku/ Bangsa : 4. Agama : 5. Pendidikan : 6. Pekerjaan : 7. Alamat : 8. Sumber Biaya : 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…………………… 1

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Page 1: Format Pengkajian Kritis

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:………………………………………………………………………………………

…………………………………………………………………………………………………………

RIWAYAT PENYAKIT SEKARANG1. Riwayat PenyakitSekarang:

………………………………………………………………………………......................................……………………………………………………………………………………………………………..........................................................................................................................................................……………………………………………………………………………………………………………..........................................................................................................................................................……………………………………………………………………………………………………………..........................................................................................................................................................

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 :

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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

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:

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................l. Lain-lain :

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........................................................................................................................................................

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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 :

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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:

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................

....................................................................................................................................................... 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:

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................o. Lain-lain:

........................................................................................................................................................

........................................................................................................................................................

........................................................................................................................................................

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 :

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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:

........................................................................................................................................................

....................................................................................................o. Nafsu makan: baik menurun Frekuensi:.......x/harip. Porsi makan: habis tidak Keterangan:.......................q. Lain-lain:

.......................................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

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 :

Page 6: Format Pengkajian Kritis

.......................................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

p. Pitting edema: +/- grade:................q. Ekskoriasis: ya tidakr. Urtikaria: ya tidaks. Lain-lain:

.......................................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

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:

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

g. Ekspresi klien terhadap penyakitnya Murung/diam gelisah tegang marah/menangish. Reaksi saat interaksi kooperatif tidak kooperatif curigai. Gangguan konsep diri:

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

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 :

Page 7: Format Pengkajian Kritis

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

TERAPI

DATA TAMBAHAN LAIN :

Surabaya, ……………..20...

(………………………)

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Page 8: Format Pengkajian Kritis

PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA

TANGGAL DATA ETIOLOGI MASALAH

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Page 9: Format Pengkajian Kritis

PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................

1.

2.

3.

4.

5.

6.

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Page 10: Format Pengkajian Kritis

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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