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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
1.
2.
3.
4.
5.
6.
7.
8.

1.

:
:
:
:

Jam Masuk
:
No. RM
:
Diagnosa Masuk :

IDENTITAS
Nama Pasien :
Umur:
Suku/ Bangsa :
Agama
:
Pendidikan
:
Pekerjaan
:
Alamat
:
Sumber Biaya :

KELUHAN UTAMA
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
:........................................................................

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..........................................................
1.

2.

OBSERVASI DAN PEMERIKSAAN FISIK


Tanda tanda vital
S:
N:
T:
RR :
Kesadaran
Compos Mentis
Apatis

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

- 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.: ..............................................................

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

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:

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


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

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

TERAPI

DATA TAMBAHAN LAIN :

Surabaya, ..20...

()

PROGRAM STUDI ILMU KEPERAWATAN


FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA
TANGGAL

DATA

ETIOLOGI

MASALAH

PROGRAM STUDI ILMU KEPERAWATAN


FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

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

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

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