FORMAT LAPORAN KASUS KEPERAWATAN GAWAT DARURAT DAN KRITIS

RUANGAN INTENSIVE

STIKes DHARMA HUSADA BANDUNG

Nama Mahasiswa :

NIM :

Ruang :

Tgl Pengkajian :

A. PENGKAJIAN

I. Identitas
a. Identitas Pasien
1) Nama inisial :
2) No RM :
3) Usia :
4) Status perkawinan :
5) Pekerjaan :
6) Agama :
7) Pendidikan :
8) Suku :
9) Alamat rumah :
10) Sumber biaya :
11) Tanggal masuk RS :
12) Diagnosa Medis :
b. Identitas Penanggungjawab
1) Nama :
2) Umur :
3) Hubungan dengan pasien :
4) Pendidikan :
5) Alamat :
II. Riwayat Kesehatan
a. Keluhan Utama

b. Riwayat kesehatan saat pengkajian/riwayat penyakit sekarang (PQRST) : Penyebab,

onset, lamanya, frequensi, intensitas, faktor pencetus, lokasi, hal yang memperberat, hal
yang memperingan.
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c. Riwayat kesehatan lalu
Riwayat alergi, riwayat kecelakaan, riwayat perawatan di RS, riwayat penyakit
berat/kronis, riwayat pengobatan, riwayat operasi
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d. Riwayat kesehatan keluarga
Genogram atau penyakit yang pernah diderita oleh anggota keluarga yang menjadi faktor
resiko, 3 generasi.
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Gambar :
 e. Riwayat psikososial dan spiritual
1. Support sistem terdiri dari dukungan keluarga, lingkungan, fasilitas kesehatan
terhadap penyakitnya.
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2. Komunikasi terdiri dari pola interaksi sosial sebelum dan saat sakit
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3. Sistem nilai kepercayaan sebelum dan saat sakit
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f. Lingkungan
1. Rumah
 Kebersihan : ________________________________________________
 Polusi : ____________________________________________________
2. Pekerjaan
 Kebersihan :________________________________________________
 Polusi : ____________________________________________________
 Bahaya : ___________________________________________________

B. 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 : Ya/ Tidak produktif tidak produktif

Sekret:…….. Konsistensi :......................

Warna:.......... Bau :..................................

c. Penggunaan otot bantu nafas:

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d. Pernapasan Cuping Hidung : ya tidak
e. Irama nafas : teratur tidak teratur
f. Penggunaaon Otot donding dada : ya tidak
g. Pola nafas : Dispnoe Kusmaul Cheyne Stokes .......................
h. Suara nafas Cracles Ronki Wheezing .............................
i. Alat bantu napas ya tidak
Jenis................................................ Flow..............lpm

j. Penggunaan WSD: Ya Tidak

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k. Tracheostomy: ya tidak
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l. Lain-lain:
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3. Sistem Kardio vaskuler (B2)

a. TD :
b. N :
c. Keluhan nyeri dada: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Irama jantung: reguler ireguler
e. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....

f. Ictus Cordis:
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g. CRT :.............detik
h. Akral: hangat kering merah basah pucat
panas dingin
i. Sikulasi perifer: normal menurun
j. Konjunctiva ananemis anemis
k. JVP :.................................
l. CVP :.................................
m. EKG & Interpretasinya:
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n. Lain-lain :
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4. Sistem Persyarafan (B3)

a. GCS : ..................................................
b. Refleks fisiologis: patella: normal/tidal triceps: normal/ tidak biceps: normal/ tidak
c. Refleks patologis babinsky brudzinsky kernig
Lain-lain :.........................................................................................................................

d. Keluhan pusing ya tidak

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

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

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

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

T :...................................................................

e. Pemeriksaan saraf kranial:

N1 : normal tidak Ket.:……..............................................................
N2 : normal tidak Ket.:……..............................................................
N3 : normal tidak Ket.:……..............................................................
N4 : normal tidak Ket.:……..............................................................
N5 : normal tidak Ket.:……..............................................................
N6 : normal tidak Ket.:……..............................................................
N7 : normal tidak Ket.:……..............................................................
N8 : normal tidak Ket.:……..............................................................
N9 : normal tidak Ket.:……..............................................................
N10: normal tidak Ket.:……..............................................................
N11: normal tidak Ket.:……..............................................................
N12: normal tidak Ket.:……..............................................................

f. Pupil anisokor isokor Diameter: ……/......

g. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur: Ya/ Tidak
h. Lain-lain:
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5. Sistem perkemihan (B4)

a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Kebersihan meatus uretra: Bersih Kotor
d. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
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e. Kemampuan berkemih:
Spontan Alat bantu, sebutkan:..................................................................
Jenis:............................................
Ukuran :............................................
Hari ke :............................................
f. Produksi urine : ………….. ml/jam
Warna :............……
Bau:......………..
g. Kandung kemih : Membesar ya tidak
h. Nyeri tekan ya tidak
i. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
j. Balance cairan:
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i. Lain-lain:
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6. Sistem pencernaan (B5)
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................

c. Mulut: bersih kotor berbau

d. Membran mukosa: lembab kering stomatitis
e. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
f. Abdomen: tegang kembun ascites
 g. Nyeri tekan: ya tidak
h. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
i. Peristaltik:.............. x/menit
j. BAB: ......................x/hari Terakhir tanggal : ......................................................
k. Konsistensi: keras lunak cair lendir/darah
l. Diet: padat lunak cair
m. Diet Khusus:
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n. Nafsu makan: baik menurun Frekuensi:.......x/hari
o. Porsi makan: habis tidak Keterangan:.......................
p. Lain-lain:
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7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior :
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b. Pengkajian fungsi penglihatan :
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c. Keluhan nyeri ya tidak

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

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

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

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

T :...................................................................

d. Luka operasi: ada tidak

 Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
e. Lain-lain :
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8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior

OD OS
Auricula
MAE
Membran
Tymphani
Rinne
Weber
Swabach

b. Tes Pendengaran
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b. Keluhan nyeri ya tidak

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

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

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

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

T :...................................................................

d. Luka operasi: ada tidak

Tanggal operasi :................
Jenis operasi :................
 Lokasi :................
Keadaan :................
e. Alat bantu dengar : .........................
f. Lain-lain :
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8. Sistem muskuloskeletal (B6)

a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot:

c. Kelainan ekstremitas: ya tidak

d. Kelainan tulang belakang: ya,......... tidak
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 : .................................................
o. Lain-lain:
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10. Sistem Integumen
a. Penilaian resiko decubitus
Aspek Yang Kriteria Penilaian Nilai
Dinilai 1 2 3 4
Persepsi Terbatas Sangat Keterbatasan Tidak Ada
Sensori Sepenuhnya Terbatas Ringan Gangguan
Kelembaban Terus Sangat Kadang2 Jarang
Menerus Lembab Basah Basah
Basah
Aktifitas Bedfast Chairfast
Kadang2 Lebih Sering
Jalan jalan
Mobilisasi Immobile Sangat Keterbatasan Tidak Ada
Sepenuhnya Terbatas Ringan Keterbatasan
Nutrisi Sangat Kemungkinan Adekuat Sangat Baik
Buruk Tidak
Adekuat
Gesekan & Bermasalah Potensial Tidak
Pergeseran Bermasalah Menimbulkan
Masalah
NOTE: Pasien dengan nilai total < 12 maka dapat dikatakan Total Nilai
bahwa pasien beresiko mengalami dekubisus (pressure
ulcers: 15 or 16 = low risk, 13 or 14 = moderate risk, 12
or less = high risk)

b. Warna
c. Pitting edema: +/- grade:................
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
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11. Sistem Endokrin

a. Pembesaran tyroid: ya tidak
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak
d. Hiperglikemia: ya tidak
e. Kondisi kaki DM
- Luka gangren ya tidak
- Jelaskan jika terdapat luka gangren :
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- Riwayat luka sebelumya ya tidak

Jika ya
- Tahun :
- Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya
- Tahun :
- Lokasi :
f. ABI : ....................................................
g. Lain-lain:
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C. PEMERIKSAN DAN PENATALAKSANAAN

I. Pemeriksaan penunjang
1) Pemeriksaan diagnostic :
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2) Pemeriksaan laboratorium : (Lampiran hasil)
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II. Penatalaksanaan medis

1) Jelaskan tindakan medis yang sudah dilakukan contohnya operasi, pemasangan alat
invasif, dll) :
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2) Pemberian obat dan jelaskan nama, dosis, cara, rute dan tujuan. :
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D. ANALISA DATA
Analisa data
No Symptom Etiologi Problem
E. DIAGNOSA KEPERAWATAN
 F.
RENCANA TINDAKAN KEPERAWATAN

Inisial Klien/Ruang : _______/______________ Nama Mahasiswa : ______________________

No. RM/Dx. Medis : ____________/_________ NIM : ______________________

PERENCANAAN
NO DIAGNOSA KEPERAWATAN
TUJUAN INTERVENSI RASIONAL
 G.
IMPLEMENTASI KEPERAWATAN

Inisial Klien/Ruang : _______/______________ Nama Mahasiswa : ______________________

No. RM/Dx. Medis : ____________/_________ NIM : ______________________

DX. HARI/TGL/JAM IMPLEMENTASI RESPON PARAF

KEPERAWATAN
H. CATATAN PERKEMBANGAN
Dx. Kep Hari/Tgl/Jam SOAP Paraf
S:

O:

A:

P:

S:

O:

A:

P:

S:

O:

A:

P:

S:

O:

A:

P:

S:

O:

A:

P:

S:

O:

A:

P:
 LAPORAN KASUS

ASUHAN KEPERAWATAN PADA Tn/Ny. (inisial)

DENGAN (judul kasus)

(RUANGAN)

Disusun Oleh

Nama :……………………….

NPM :…………………………

Pembimbing Klinik

( )

PROGRAM PROFESI NERS

PROGRAM STUDI SARJANA KEPERAWATAN

STIKES DHARMA HUSADA BANDUNG

2019