pengkajian keperawatan intensif
TRANSCRIPT
PROGRAM PROFESI/NERS KEPERAWATANSTASE KEPERAWATAN KRITISPROGRAM B5 STIKES WIRA MEDIKA PPNI BALITAHUN AJARAN 2014/2015
ASUHAN KEPERAWATAN KRITIS
PADA...................DENGAN............................................................................................
DI RUANG..................................... RS SANGLAH DENPASAR
Nama Mahasiswa:
NIM:
Tgl/ Jam: No. RM :Ruangan: Diagnosis Medis :
IDENTITASNama/Inisial: Jenis Kelamin :Umur: Status Perkawinan :Agama: Sumber Informasi :Pendidikan : Hubungan :Pekerjaan :Suku/ Bangsa :Alamat :
RIWAYAT SAKIT DAN KESEHATANKeluhan utama saat MRS:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Keluhan utama saat pengkajian:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Riwayat penyakit saat ini:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Riwayat Allergi:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Riwayat Pengobatan: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
BREATHINGJalan Nafas: Paten Tidak PatenObstruksi: Lidah Cairan Benda Asing Tidak Ada Muntahan Darah OedemaSuara Nafas: Snoring Gurgling Stridor Tidak adaNafas: Spontan Tidak SpontanGerakan dinding dada: Simetris AsimetrisIrama Nafas : Cepat Dangkal NormalPola Nafas : Teratur Tidak TeraturJenis: Dispnoe Kusmaul Cyene Stoke Lain Suara Nafas: Vesikuler Stidor Wheezing RonchiSesak Nafas : Ada Tidak AdaCuping hidung Ada Tidak AdaRetraksi otot bantu nafas : Ada Tidak AdaPernafasan : Pernafasan Dada Pernafasan PerutBatuk: Ya Tidak ada Sputum: Ya , Warna: ... ... ... Konsistensi: ... ... ... Volume: ... Bau: Tidak RR : ... ... x/mntAlat bantu nafas: OTT ETT Trakeostomi Ventilator, Keterangan: ... ... ...Oksigenasi : ... ... lt/mnt Nasal kanul Simpel mask Non RBT mask RBT Mask Tidak adaLain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MasalahKeperawatan:
BLOODNadi: TerabaTidakteraba N: x/mntTekananDarah : mmHgPucat: Ya TidakSianosis: Ya TidakCRT :< 2 detik > 2 detikAkral : Hangat Dingin S: ... ...CPendarahan: Ya, Lokasi: ... ... Jumlah ... ...cc TidakTurgor:ElastisLambatDiaphoresis: Ya TidakRiwayatKehilangancairanberlebihan: DiareMuntah Luka bakarIVFD : Ya Tidak, Jeniscairan: Lain: ... ... ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MasalahKeperawatan:
BRAINKesadaran: Composmentis Delirium SomnolenApatisKomaGCS: Eye ... Verbal ...Motorik ...Pupil: IsokorUnisokorPinpointMedriasisRefleksCahaya: Ada Tidak AdaRefleksfisiologis: Patela (+/-) Lain-lain Refleks patologis: Babinzky (+/-) Kernig (+/-) Lain-lain ... ...Refleks pada bayi: Refleks Rooting (+/-) Refleks Moro (+/-) (Khusus PICU/NICU) Refleks Sucking (+/-) Bicara : Lancar Cepat Lambat Tidur malam: jam Tidur siang: jamAnsietas: Ada Tidak adaLain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Masalah Keperawatan:
BLADDERNyeri pinggang: Ada TidakBAK : Lancar Inkontinensia Anuri Nyeri BAK : Ada Tidak adaFrekuensi BAK : Warna: ... ... Darah : Ada Tidak adaKateter : Ada Tidak ada, Urine output: ... ... Lain: ... ... ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Masalah Keperawatan:
BOWELTB : ... ...cm BB : ... ...kgNafsu makan : Baik MenurunKeluhan : Mual Muntah Sulit menelanMakan : Frekuensi ... ...x/hr Jumlah : ... ... porsiMinum : Frekuensi ... ... gls /hr Jumlah : ... ... cc/hrPerut kembung : Ya TidakBAB : Teratur Tidak Frekuensi BAB : ... ...x/hr Konsistensi: ... ... .. Warna: ... ... darah (+/-)/lendir(+/-)Lain : ... ...________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Masalah Keperawatan:
BONE(Muskuloskletal & Integumen)Nyeri : Ada TidakProblem : ... ...Qualitas/ Quantitas: ... ...Regio : ... ...Skala: ... ...Timing: ... ...Kekuatan otot : ... ...
Deformitas : Ya TidakLokasi ... ...Contusio: Ya TidakLokasi ... ...Abrasi: Ya TidakLokasi ... ...Penetrasi: Ya TidakLokasi ... ...Laserasi: Ya TidakLokasi ... ...Edema: Ya TidakLokasi ... ...Luka Bakar: Ya TidakLokasi ... ...Grade : ... ... %
Jika ada luka/ vulnus, kaji:Luas Luka: ... ... Warna dasar luka: ... ...Kedalaman : ... ...
Keterangan:0;Mandiri1;Alatbantu2;Dibantu orang lain3;Dibantu orang lain & alat4;Tergantung totalAktivitas dan latihan: 0 1 2 3 4Makan/minum: 0 1 2 3 4Mandi: 0 1 2 3 4Toileting: 0 1 2 3 4Berpakaian : 0 1 2 3 4Mobilisasi di tempat tidur: 0 1 2 3 4Berpindah: 0 1 2 3 4Ambulasi: 0 1 2 3 4
Lain-lain : ... ...________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Masalah Keperawatan:
HEAD TO TOE(Fokus pemeriksaan pada daerah trauma/sesuai kasus non trauma)Kepala dan wajah:
Leher:
Dada:
Abdomen dan Pinggang:
Pelvis dan Perineum:
Ekstremitas:
Masalah Keperawatan:
TEST DIAGNOSTIK DAN TERAPI MEDISHasil laboratorium TglpemeriksaanNoHasil pemeriksaanNilai normalKeterangan
Terapi medis saat ini (TGL): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Masalah Keperawatan:
MENGETAHUI,
Pembimbing lapangan,Pembimbing Akademik,
(......................................)(....................................)
Mahasiswa,
(.......................................)
DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS
1. ..2. ..3. ..4. ..5. ..