Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis

Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014
ASUHAN KEPERAWATAN KRITIS
.
.
.
Tgl/ Jam
Ruangan

Tanggal MRS

Diagnosis Medis :
Penanggung jawab

IDENTITAS

Pasien

Nama/Inisial

Nama/Inisial

Jenis Kelamin

Jenis Kelamin

Umur

Umur

Agama

Agama

Pendidikan

Pendidikan

Pekerjaan

Pekerjaan

Suku/ Bangsa

Suku Bangsa

Status Perkawinan :
No. RM

Hubungan dengan pasien :

Alamat
:
Keluhan utama saat MRS

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Keluhan utama saat pengkajian

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RIWAYAT SAKIT DAN KESEHATAN

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Riwayat penyakit saat ini

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Riwayat Allergi

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Riwayat Pengobatan

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Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga:
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Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis
Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014
Jalan Nafas

: Paten

Tidak Paten

Obstruksi

: Lidah

Cairan

Benda Asing

Darah

Oedema

Gurgling

Stridor

Muntahan
Suara Nafas: Snoring

BREATHING

Nafas

: Spontan

Tidak Ada

Tidak ada

Tidak Spontan

Gerakan dinding dada: Simetris

Asimetris

Irama Nafas

: Cepat

Dangkal

Normal

Pola Nafas

: Teratur

Tidak Teratur

Jenis

: Dispnoe Kusmaul

Cyene Stoke

Lain

Suara Nafas

: Vesikuler Stidor

Wheezing

Ronchi

Sesak Nafas

: Ada

Tidak Ada

Cuping hidung Ada

Tidak Ada

Retraksi otot bantu nafas : Ada Tidak Ada

Pernafasan : Pernafasan Dada
Batuk

: Ya

Pernafasan Perut

Tidak ada

Sputum: Ya , Warna: ... ... ... Konsistensi: ... ... ... Volume: ... Bau:
Tidak
RR : ... ... x/mnt
Alat bantu nafas: OTT ETT Trakeostomi
Ventilator, Keterangan: ... ... ...
Oksigenasi : ... ... lt/mnt Nasal kanul Simpel mask Non RBT mask
ada
Lain:

BLOOD

Masalah Keperawatan:
Nadi

: Teraba

Tidak teraba

N: x/mnt

Tekanan Darah : mmHg

Pucat

: Ya

Tidak

Sianosis

: Ya

Tidak

CRT

: < 2 detik

> 2 detik

Akral

: Hangat

Dingin

Pendarahan

: Ya, Lokasi: ... ... Jumlah ... ...cc

Turgor

: Elastis

Diaphoresis: Ya

S: ... ...C
Tidak

Lambat
Tidak

Riwayat Kehilangan cairan berlebihan: Diare Muntah Luka bakar

IVFD : Ya Tidak, Jenis cairan:
Lain: ... ... \
Masalah Keperawatan:

RBT Mask

Tidak

Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis
Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014
Kesadaran: Composmentis Delirium Somnolen Apatis Koma
GCS

: Eye ...

Verbal ...

Motorik ...

Pupil

: Isokor

Unisokor

Pinpoint

Refleks Cahaya: Ada Tidak Ada

Refleks fisiologis: Patela (+/-) Lain-lain
Refleks patologis : Babinzky (+/-) Kernig (+/-) Lain-lain ... ...

BRAIN

Refleks pada bayi: Refleks Rooting (+/-) Refleks Moro (+/-)

(Khusus PICU/NICU) Refleks Sucking (+/-)
Bicara : Lancar Cepat

Lambat

Tidur malam : jam Tidur siang : jam

Ansietas : Ada Tidak ada
Lain :

Masalah Keperawatan:

Nyeri pinggang: Ada

BAK : Lancar

Inkontinensia

Tidak
Anuri

Nyeri BAK : Ada Tidak ada

Frekuensi BAK : Warna: ... ... Darah : Ada
Kateter : Ada Tidak ada, Urine output: ... ...

BLADDER

Lain: ... ...

Masalah Keperawatan:

Tidak ada

Medriasis

Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis
Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014
TB : ... ...cm BB : ... ...kg
Nafsu makan : Baik Menurun
Keluhan : Mual

Muntah

Sulit menelan

Makan : Frekuensi ... ...x/hr Jumlah : ... ... porsi

Minum : Frekuensi ... ... gls /hr Jumlah : ... ... cc/hr
Perut kembung : Ya

Tidak

BAB : Teratur Tidak

BOWEL

Frekuensi BAB : ... ...x/hr Konsistensi: ... ... .. Warna: ... ... darah (+/-)/lendir(+/-)
Lain : ... ...

(Muskuloskletal & Integumen) BONE

Masalah Keperawatan:

Nyeri : Ada

Tidak

Problem

: ... ...

Qualitas/ Quantitas

: ... ...

Regio

: ... ...

Skala

: ... ...

Timing

: ... ...

Kekuatan otot : ... ...

Deformitas

: Ya

Tidak

Lokasi ... ...

Contusio

: Ya

Tidak

Lokasi ... ...

Abrasi

: Ya

Tidak

Lokasi ... ...

Penetrasi

: Ya

Tidak

Lokasi ... ...

Laserasi

: Ya

Tidak

Lokasi ... ...

Edema

: Ya

Tidak

Lokasi ... ...

Luka Bakar

: Ya

Tidak

Lokasi ... ...

Grade : ... ... %

Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis
Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014

Jika ada luka/ vulnus, kaji:

Luas Luka

: ... ...

Warna dasar luka: ... ...

Kedalaman : ... ...
Keterangan:

Aktivitas dan latihan

:0

0;3 Mandiri
4

Makan/minum

:0

2;3 Dibantu
4 orang lain

Mandi

:0

4;3 Tergantung
4 total

Toileting

:0

Berpakaian

:0

Mobilisasi di tempat tidur : 0

Berpindah

:0

Ambulasi

:0

Lain-lain : ... ...

Masalah Keperawatan:

1; Alat bantu

3; Dibantu orang lain & alat

Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis
Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014
(Fokus pemeriksaan pada daerah trauma/sesuai kasus non trauma)
Kepala dan wajah

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Leher

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Dada

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HEAD TO TOE

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Abdomen dan Pinggang

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Pelvis dan Perineum

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Ekstremitas

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Masalah Keperawatan:

Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis
Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014
Hasil laboratorium (TGL):
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TEST DIAGNOSTIK DAN TERAPI MEDIS

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Terapi medis saat ini (TGL):
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Program Profesi/Ners Keperawatan

Stase Keperawatan Kritis
Program B4 Stikes Wira Medika PPNI Bali
Tahun Ajaran 2013/2014

Mengetahui,

Mengetahui
Pembimbing Praktek (CI)

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

Mahasiswa

I Komang Adi Nurjayana

NIM. 13.901.0269

Mengetahui
Pembimbing Akademik,

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