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PROGRAM STUDI PENDIDIKAN NERSFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGAPENGALAMAN BELAJAR PRAKTIKA

FORMAT PENGKAJIAN KEPERAWATAN KRITISTanggal 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 UTAMA1. Keluhan utama:

RIWAYAT PENYAKIT SEKARANG

1. Riwayat PenyakitSekarang:....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat

: ya tidak kapan : diagnosa :

2. Riwayat penyakit kronik dan menular yatidak jenis

Riwayat kontrol : .............................

Riwayat penggunaan obat :..............

3. Riwayat alergi:

Obatya tidakjenis

Makanan yatidakjenis

Lain-lain yatidakjenis

4. Riwayat operasi:

ya tidak

Kapan :

Jenis operasi :

5. Lain-lain:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT KESEHATAN KELUARGA

Ya

tidak

Jenis:........................................................................ Genogram:

PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan:

Alkoholya tidakketerangan.........................................................

Merokokyatidak

keterangan.........................................................

Obatyatidak

keterangan..............................................................

Olahraga yatidak

keterangan..........................................................OBSERVASI DAN PEMERIKSAAN FISIK

1. 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

produktiftidak produktif

Sekret:..

Konsistensi :......................

Warna:..........

Bau :..................................

c. Penggunaan otot bantu nafas:...............................................................................................................................................................................................................................................................................................................d. Irama nafas

teratur

tidak teratur

e. Pleural Friction rub:.....................................................................................................................f. Pola nafas

Dispnoe

KusmaulCheyne Stokes Biotg. Suara nafas

Cracles

Ronki

Wheezingh. Alat bantu napas

ya tidak

Jenis................................................Flow..............lpmVentitalor

Mode:

FiO2:

PEEP:

SaO2:

Vol. Tidal:

I:E Ratio:

Lain-lain :

i. Penggunaan WSD: Jenis: ...................................................................................................................... Jumlah cairan: ...................................................................................................................... Undulasi:...................................................................................................................... Tekanan: ......................................................................................................................j. Tracheostomy: yatidak

...............................................................................................................................................................................................................................................................................................................k. Lain-lain:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Sistem Kardio vaskuler (B2)a. Keluhan nyeri dada:

ya

tidak

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:hangatkeringmerahbasahpucat

panasdinging. Sikulasi perifer: normal menurunh. JVP:.................................i. CVP:.................................

j. CTR:.................................k. ECG & Interpretasinya:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................l. Lain-lain :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4. Sistem Persyarafan (B3)a. GCS : ..................................................b. Refleks fisiologis

patella

triceps

biceps

c. Refleks patologis

babinskybrudzinskykernigLain-laind. Keluhan pusing

ya

tidak

P:...................................................................

Q:...................................................................

R:...................................................................

S:...................................................................

T:...................................................................e. Pemeriksaan saraf kranial:N1:normaltidak

Ket.: ..............................................................

N2:normaltidak

Ket.: ..............................................................

N3:normaltidak

Ket.: ..............................................................

N4:normaltidak

Ket.: ..............................................................

N5:normaltidak

Ket.: ..............................................................

N6:normaltidak

Ket.: ..............................................................

N7:normaltidak

Ket.: ..............................................................

N8:normaltidak

Ket.: ..............................................................

N9:normaltidak

Ket.: ..............................................................

N10:normaltidak

Ket.: ..............................................................

N11:normaltidak

Ket.: ..............................................................

N12:normaltidak

Ket.: ..............................................................

f. Hoffman/Tromer test:

g. Pupil

anisokor

isokor

Diameter: /......

h. Sclera anikterusikterus

i. 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 Kotor

b. Sekret: Ada Tidakc. Ulkus: Ada Tidakd. Kebersihan meatus uretra: Bersih Kotor

e. Keluhan kencing: Ada TidakBila ada, jelaskan:

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

f. Kemampuan berkemih:SpontanAlat 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 cairanoral : cc/hari parenteral : cc/hari

k. Balance cairan:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................o. Lain-lain:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

6. Sistem pencernaan (B5)a. TB:............... BB:................................b. IMT:...............Interpretasi:................................c. LOLA:...............

d. Mulut:

bersih

kotor

berbau

e. Membran mukosa:

lembab

kering

stomatitis

f. Tenggorokan:

sakit menelankesulitan menelan

pembesaran tonsilnyeri tekan

g. Abdomen: tegang kembungascites

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: keraslunakcairlendir/darah

m. Diet:padatlunakcair

n. Diet Khusus:

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

o. Nafsu makan:baikmenurun

Frekuensi:.......x/hari

p. Porsi makan: habistidak

Keterangan:.......................

q. Lain-lain:

.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................7. Sistem muskuloskeletal (B6)a. Pergerakan sendi: bebas terbatas

b. Kekuatan otot:

c. Kelainan ekstremitas:yatidak

d. Kelainan tulang belakang:ya tidak

Frankel: ................................................................................e. Fraktur: yatidak

Jenis:...................

f. Traksi:yatidak

Jenis:...................

Beban:...................

Lama pemasangan:...................

g. Penggunaan spalk/gips:yatidak

h. Keluhan nyeri:ya tidak

P:...................................................................

Q:...................................................................

R:...................................................................

S:...................................................................

T:...................................................................i. Sirkulasi perifer: ..............................................j. Kompartemen syndromeya tidak

k. Kulit:ikteriksianosis kemerahanhiperpigmentasi

l. Turgor baik kurang jelek

m. Luka operasi: adatidak

Tanggal operasi :................

Jenis operasi :................

Lokasi :................

Keadaan :................

Drain :adatidak

Jumlah :...................

Warna :...................

Kondisi area sekitar insersi :...................

n. ROM:................................................o. Lain-lain:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

p. Pitting edema: +/- grade:................

q. Ekskoriasis:ya tidak

r. Urtikaria:ya tidak

s. Lain-lain:

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

8. Sistem Endokrin

a. Pembesaran tyroid:yatidak

b. Pembesaran kelenjar getah bening:yatidak

c. Hipoglikemia:yatidak

d. Hiperglikemia:yatidake. Lain-lain:..................Jelaskan:..................................................

PENGKAJIAN PSIKOSOSIAL

f. Persepsi klien terhadap penyakitnya:.............................................................................................................................................................................................................................................................................................................................................................................................

g. Ekspresi klien terhadap penyakitnya

Murung/diam gelisah tegang marah/menangis

h. Reaksi saat interaksi kooperatiftidak kooperatif curiga

i. Gangguan konsep diri:

.............................................................................................................................................................................................................................................................................................................................................................................................j. Lain-lain:...............................................................................................................................

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

...............................................................................................................................PERSONAL HYGIENE & KEBIASAAN

Jelaskan

PENGKAJIAN SPIRITUAL

a. Kebiasaan beribadah

Sebelum sakit sering kadang- kadangtidak pernah

Selama sakit sering kadang- kadangtidak pernah

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

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

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

TERAPIDATA TAMBAHAN LAIN :Surabaya, ..20...()

PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA

TANGGALDATAETIOLOGIMASALAH

PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................1.

2.

3.

4.

5.6. RENCANA INTERVENSIHARI/

TANGGALWAKTUDIAGNOSA KEPERAWATAN

(Tujuan, Kriteria Hasil)INTERVENSIRASIONAL

IMPLEMENTASI DAN EVALUASI KEPERAWATANHari/Tgl/ShiftNo. DKJamImplementasiParafJamEvaluasi (SOAP)Paraf

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