PROGRAM STUDI PENDIDIKAN NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

PENGALAMAN BELAJAR PRAKTIKA

FORMAT PENGKAJIAN KEPERAWATAN KRITIS

Tgl/ Jam : 02/03/2018 Tanggal MRS : 02/03/2018
Ruangan : ICU Diagnosis Medis : CHF ,Syok Kardiogenik

IDENTITAS
Nama/Inisial : Tn.R No.RM : 4457688
Jenis Kelamin : Laki-laki Suku/ Bangsa : Jawa
Umur : 71 tahun Status Perkawinan : Kawin
Agama : Islam Penanggung jawab : Ny.H
Pendidikan : Hubungan : Istri
Pekerjaan : Pensiunan PNS Pekerjaan : IRT
Alamat : Surakarta
KELUHAN UTAMA
1. Keluhan utama : Sesak napas

RIWAYAT PENYAKIT SEKARANG

1. Riwayat PenyakitSekarang:
2. Pasien megatakan sesak napas +/- 2 jam sebelum masuk rumah sakit,
dibawa ke IGD Rumah Sakit pada tanggal 28/02/2018 jam 10.00 WIB, dengan
TD : 90/50mmHg, N : 60 x/menit, RR: 28 x/menit T: 36,1°C. Kemudian
pasien dirawat di ruang Cemara sampai tanggal 02/03/2018, pasien pindah ke
ruang ICU tanggal 02/03/2018 jam 15.00 WIB dengan keluhan sesak napas,
KU lemah, Kesadaran composmentis, saat dikaji TD : 100/75 mmHg, N : 83
x/menit, RR : 27 x/menit, S: 37 0C.

RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat : ya tidak kapan : 1 tahun lalu diagnosa : CHF
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: ya tidak

- Kapan : ……………………
- Jenis operasi : ……………………

5. Lain-lain:
................................................................................................................................................................
.................................................................................................................................................................
................................................................................................................................................................

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RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis :…………………........................................................................
-
- Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATAN Masalah Keperawatan :

Perilaku sebelum sakit yang mempengaruhi kesehatan: Pola Nafas Tidak efektif
Alkohol ya tidak
keterangan…………………….........................................................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olahraga ya tidak
Keterangan : Klien dirumah jarang melakukan olahraga

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
TD : 100/75 mmHg N :83x/menit T : 37 RR : 27x/menit
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma

2. Sistem Pernafasan (B1)

a. RR : 27x/menit
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. : Nasal canule. Flow : .4 .lpm

Ventitalor
Mode :
FiO2 :
PEEP :
SaO2 :
Vol. Tidal:
I:E Ratio:
2
 Lain-lain :

i. Penggunaan WSD:
- Jenis : ......................................................................................................................
- Jumlah cairan : ......................................................................................................................
- Undulasi :......................................................................................................................
- Tekanan : ......................................................................................................................
j. Tracheostomy: ya tidak
........................................................................................................................................................
.......................................................................................................................................................
k. Lain-lain:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

3. Sistem Kardio vaskuler (B2)

a. Keluhan
Masalah Keperawatannyeri dada:: ya tidak
P : proses penyakit/agaen
Nyeri Akut b/d agen pencedera pencedera fisiologis
Q :tertusuk-tusuk.
fisiologis
R :dada kiri
S :.skala 5
T :hilang timbul
b. Irama jantung: reguler ireguler
c. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
d. Ictus Cordis: Teraba
e. CRT : < 3detik
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 : E4M6V5 Masalah Keperawatan :
b. Refleks fisiologis patella triceps biceps
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.: ……..............................................................
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 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. Hoffman/Tromer test :
g. Pupil anisokor isokor Diameter: /......
h. Sclera anikterus ikterus
i. Konjunctiva ananemis anemis
j. Isitrahat/Tidur 7-8 Jam/Hari Gangguan tidur : ........................
k. IVD :................................................
l. EVD :................................................
m. ICP :................................................
n. 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 : 100 ml/jam
Warna : kuning jernih
Bau :.khas urine
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : 600-700 cc/hari parenteral : 500 cc/hari
k. Balance cairan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
o. Lain-lain:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

6. Sistem pencernaan (B5)

a. TB : 156 cm BB :54kg Masalah Keperawatan :
b. IMT :............... Interpretasi :................................
4
 c. LOLA :...............

d. Mulut: bersih kotor berbau

e. Membran mukosa: lembab kering stomatitis
f. Tenggorokan:
sakit menelan 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:11. x/menit
k. BAB:1 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:. 3x/hari
p. Porsi makan: habis tidak Keterangan:.......................
q. Lain-lain:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

7. Sistem muskuloskeletal (B6)

a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot: 5 5

4 4
c. Kelainan ekstremitas: ya tidak
Masalah Keperawatan :
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 :...................
5
 - Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : ................................................

o. Lain-lain:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

p. Pitting edema: +/- grade:................

q. Ekskoriasis: ya tidak
Masalah Keperawatan :
r. Urtikaria: ya tidak
s. Lain-lain:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

8. Sistem Endokrin
a. Pembesaran tyroid: ya tidak Masalah Keperawatan :
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak
d. Hiperglikemia: ya tidak
e. Lain-lain:..................Jelaskan:..................................................

PENGKAJIAN PSIKOSOSIAL Masalah keperawatan :

f. Persepsi klien terhadap penyakitnya:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

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 Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

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b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

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

TERAPI

DATA TAMBAHAN LAIN :

Surabaya, ……………..20...

(………………………)

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 PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA

TANGGAL DATA ETIOLOGI MASALAH

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 PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

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

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 RENCANA INTERVENSI

HARI/ DIAGNOSA KEPERAWATAN

WAKTU INTERVENSI RASIONAL
TANGGAL (Tujuan, Kriteria Hasil)

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 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/Tgl/Shift No. DK Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf

11
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