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

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

- 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

12