FORMAT ASUHAN KEPERAWATAN KRITIS

Nama mahasiswa : ........................................................................

Semester/Tingkat : ........................................................................
Tempat Praktek : ........................................................................
Tanggal Pengkajian : ........................................................................

DATA KLIEN

A. DATA UMUM

1. Nama inisial klien : ........................................................................

2. Umur : ........................................................................
3. Alamat : ........................................................................
4. Agama : ........................................................................
5. Tanggal masuk RS/RB : ........................................................................
6. Nomor rekam medis : ........................................................................
7. Diagnosa medis : ........................................................................
8. Bangsal : ........................................................................

B. PENGKAJIAN
1. HEALTH PROMOTION
a. Kesehatan Umum:
1) Alasan masuk rumah sakit:
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
2) Tekanan darah : ..................................................................................
3) Nadi : ..................................................................................
4) Suhu : ..................................................................................
5) Respirasi : ..................................................................................

b. Riwayat masa lalu (penyakit, kecelakaan,dll):

...................................................................................................................
...................................................................................................................
...................................................................................................................
 c. Riwayat pengobatan
No Nama obat/jamu Dosis Keterangan
1.

2.

3.

d. Kemampuan mengontrol kesehatan:

1) Yang dilakukan bila sakit :
.............................................................................................................
.............................................................................................................
.............................................................................................................

2) Pola hidup (konsumsi/alkohol/olah raga, dll)

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

e. Faktor sosial ekonomi (penghasilan/asuransi kesehatan, dll):

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

f. Pengobatan sekarang:
No Nama obat Dosis Kandungan Manfaat
1.
2.
3.
4.

2. NUTRITION
a. A (Antropometri) meliputi BB, TB, LK, LD, LILA, IMT:
1) BB biasanya: .............Kg dan BB sekarang: ...........Kg
2) Lingkar perut : ............................................................
3) Lingkar kepala : ............................................................
4) Lingkar dada : ............................................................
5) Lingkar lengan atas : ............................................................
6) IMT : ............................................................

b. B (Biochemical) meliputi data laboratorium yang abormal:

...................................................................................................................
...................................................................................................................
...................................................................................................................
c. C (Clinical) meliputi tanda-tanda klinis rambut, turgor kulit, mukosa
bibir, conjungtiva anemis/tidak:
...................................................................................................................
...................................................................................................................
...................................................................................................................

d. D (Diet) meliputi nafsu, jenis, frekuensi makanan yang diberikan

selama di rumah sakit:
...................................................................................................................
...................................................................................................................
...................................................................................................................

e. E (Energy) meliputi kemampuan klien dalam beraktifitas selama di

rumah sakit:
...................................................................................................................
...................................................................................................................
...................................................................................................................

f. F (Factor) meliputi penyebab masalah nutrisi: (kemampuan menelan,

mengunyah,dll)
...................................................................................................................
...................................................................................................................
...................................................................................................................

g. Penilaian Status Gizi

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

h. Pola asupan cairan

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

i. Cairan masuk
...................................................................................................................
...................................................................................................................
...................................................................................................................

j. Cairan keluar
...................................................................................................................
...................................................................................................................
...................................................................................................................
 k. Penilaian Status Cairan (balance cairan)
...................................................................................................................
...................................................................................................................
...................................................................................................................

l. Pemeriksaan Abdomen (sistem elimination juga)

Inspeksi : ....................................................................................
....................................................................................
....................................................................................
....................................................................................
Auskultasi : ....................................................................................
....................................................................................
....................................................................................
....................................................................................
Palpasi : ....................................................................................
....................................................................................
....................................................................................
....................................................................................
Perkusi : ....................................................................................
....................................................................................
....................................................................................
....................................................................................

3. ELIMINATION
a. Sistem Urinary
1) Pola pembuangan urine (frekuensi, jumlah, ketidaknyamanan)
.............................................................................................................
.............................................................................................................
.............................................................................................................

2) Riwayat kelainan kandung kemih

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

3) Pola urine (jumlah, warna, kekentalan, bau)

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

4) Distensi kandung kemih/retensi urine

.............................................................................................................
.............................................................................................................
 b. Sistem Gastrointestinal
1) Pola eliminasi (jumlah, frekuensi, warna, konsistensi, bau, lendir)
.............................................................................................................
.............................................................................................................
.............................................................................................................

2) Konstipasi dan faktor penyebab konstipasi

.............................................................................................................
.............................................................................................................
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3) Diare dan faktor penyebab diare

.............................................................................................................
.............................................................................................................
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c. Sistem Integument
1) Kulit (integritas kulit/ hidrasi/ turgor / warna/ suhu)
.............................................................................................................
.............................................................................................................
.............................................................................................................

4. ACTIVITY/REST
a. Istirahat/tidur
1) Jam tidur : ..................................................................................
2) Insomnia : ..................................................................................
3) Pertolongan untuk merangsang tidur:
...............................................................................................................
...............................................................................................................

b. Aktivitas
1) Pekerjaan : ....................................................................
2) Kebiasaan olah raga : ....................................................................
3) ADL
a) Makan : ....................................................................
b) Toileting : ....................................................................
c) Kebersihan : ....................................................................
d) Berpakaian : ....................................................................
4) Bantuan ADL : ....................................................................
No Item yang dinilai Skor Nilai
1. Makan (Feeding) 0 = Tidak mampu
1 = Butuh bantuan
2 = Mandiri
2. Mandi (Bathing) 0 = Tergantung orang lain
1 = Mandiri
3. Perawatan 0 = Membutuhkan
 diri(Grooming) bantuan orang lain
1 = Mandiri dalam
perawatan muka,
rambut, gigi, dan
bercukur
4. Berpakaian(Dressi 0 = Tergantung orang lain
ng) 1 = Sebagian
dibantu (msl:
mengancing baju)
2 = Mandiri
5. Buang air 0 = Inkontinensia atau
kecil(Bowel) pakai kateter dan
tidak terkontrol
1 = Kadang Inkontinensia
(maks,1x24 jam)
2 = Kontinensia (teratur >
7 hari)
6. Buang 0 = Inkontinensia (tidak
air besar(Bladder) teratur atau perlu
enema)
1 =Kadang Inkontensia
(sekali seminggu)
2 =Kontinensia (teratur)
7. Penggunaan toilet 0 = Tergantung bantuan
orang lain
1 = Membutuhkan
bantuan, tapi dapat
melakukan beberapa
hal sendiri
2 = Mandiri
8. Transfer 0 = Tidak mampu
1 = Butuh bantuan untuk
bisa duduk (2 orang)
2 = Bantuan kecil (1
orang)
3 = Mandiri
9. Mobilitas 0 = Immobile (tidak
mampu)
1 = Menggunakan kursi
roda
2 = Berjalan dengan
bantuan satu orang
3 = Mandiri (meskipun m
enggunakan alat
bantu
seperti, tongkat)
 10. Naik turun tangga 0 =Tidak mampu
1 =Membutuhkan
bantuan (alat bantu)
2 =Mandiri
Interpretasi hasil :
20 : Mandiri
12-19 : Ketergantungan Ringan
9-11 : Ketergantungan Sedang
5-8 : Ketergantungan Berat
0-4 : Ketergantungan Total

5) Kekuatan otot : ....................................................................

6) ROM : ....................................................................

7) Resiko untuk cidera : ....................................................................

c. Cardio respons
1) Penyakit jantung : ....................................................................
2) Edema esktremitas : ....................................................................
3) Tekanan darah dan nadi
a) Berbaring : ....................................................................
b) Duduk : ....................................................................
4) Tekanan vena jugularis: ....................................................................
5) Pemeriksaan jantung
a) Inspeksi : .......................................................................
.......................................................................
.......................................................................
b) Palpasi : .......................................................................
.......................................................................
.......................................................................
c) Perkusi : .......................................................................
.......................................................................
.......................................................................
d) Auskultasi : .......................................................................
.......................................................................
.......................................................................

d. Pulmonary respon
1) Penyakit sistem nafas : .......................................................................
2) Penggunaan O2 : ..................................................................................
3) Kemampuan bernafas : .......................................................................
 4) Gangguan pernafasan (batuk, suara nafas, sputum, dll)
.............................................................................................................
.............................................................................................................
.............................................................................................................

5) Pemeriksaan paru-paru
a) Inspeksi : .......................................................................
.......................................................................
.......................................................................
b) Palpasi : .......................................................................
.......................................................................
.......................................................................
c) Perkusi : .......................................................................
.......................................................................
.......................................................................
d) Auskultasi : .......................................................................
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.......................................................................

5. PERCEPTION/COGNITION
a. Orientasi/kognisi
1) Tingkat pendidikan : ..........................................................
2) Kurang pengetahuan : ..........................................................
3) Pengetahuan tentang penyakit : ..........................................................
4) Orientasi (waktu, tempat, orang) :
.............................................................................................................
.............................................................................................................
.............................................................................................................

b. Sensasi/persepsi
1) Riwayat penyakit jantung : ..........................................................
2) Sakit kepala : ..........................................................
3) Penggunaan alat bantu : ..........................................................
4) Penginderaan : ..........................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................

c. Communication
1) Bahasa yang digunakan : ..........................................................
2) Kesulitan berkomunikasi : ..........................................................
6. SELF PERCEPTION
a. Self-concept/self-esteem
1) Perasaan cemas/takut : ..........................................................
2) Perasaan putus asa/kehilangan : ..........................................................
3) Keinginan untuk mencederai : ..........................................................
4) Adanya luka/cacat : ..........................................................

7. ROLE RELATIONSHIP
a. Peranan hubungan
1) Status hubungan : ..........................................................
2) Orang terdekat : ..........................................................
3) Perubahan konflik/peran : ..........................................................
4) Perubahan gaya hidup : ..........................................................
5) Interaksi dengan orang lain : ..........................................................

8. SEXUALITY
a. Identitas seksual
1) Masalah/disfungsi seksual : ..........................................................
2) Periode menstruasi : ..........................................................
3) Metode KB yang digunakan : ..........................................................
4) Pemeriksaan SADARI : ..........................................................
5) Pemeriksaan papsmear : ..........................................................

9. COPING/STRESS TOLERANCE
a. Coping respon
1) Rasa sedih/takut/cemas :
.............................................................................................................
.............................................................................................................

2) Kemampan untuk mengatasi :

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

3) Perilaku yang menampakkan cemas :

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

10. LIFE PRINCIPLES

a. Nilai kepercayaan
1) Kegiatan keagamaan yang diikuti :
.............................................................................................................
.............................................................................................................

2) Kemampuan untuk berpartisipasi :

.............................................................................................................
.............................................................................................................
 3) Kegiatan kebudayaan :
.............................................................................................................
.............................................................................................................

4) Kemampuan memecahkan masalah :

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

11. SAFETY/PROTECTION
a. Alergi : ......................................................................
b. Penyakit autoimune : ......................................................................
c. Tanda infeksi : ......................................................................
d. Gangguan thermoregulasi : ......................................................................
e. Gangguan/resiko (komplikasi immobilisasi, jatuh, aspirasi, disfungsi
neurovaskuler peripheral, kondisi hipertensi, pendarahan, hipoglikemia,
Sindrome disuse, gaya hidup yang tetap) :
...................................................................................................................
...................................................................................................................
...................................................................................................................

12. COMFORT
a. Kenyamanan/Nyeri
1) Provokes (yang menimbulkan nyeri) : ..............................................
2) Quality (bagaimana kualitasnya) : ..............................................
3) Regio (dimana letaknya) : ..............................................
4) Scala (berapa skalanya) : ..............................................
5) Time (waktu) : ..............................................
b. Rasa tidak nyaman lainnya : ..........................................................
c. Gejala yang menyertai : ..........................................................

13. GROWTH/DEVELOPMENT
Pertumbuhan dan perkembangan :
........................................................................................................................
........................................................................................................................
........................................................................................................................

C. CATATAN PERKEMBANGAN
Keadaan Umum :
JAM
TD
TTV NADI
RR
 SUHU
EYE
GCS MOTORIK
VERBAL

Data Penghitungan Balance Cairan

Hari/Tanggal : .........................................................................
Input : ......................................................................................
- Minum : ______ ml (Normal: 2000 ml/hari)
- Makan : ______ ml (Normal: 300 ml/hari)
- Infus : ______ ml (Amati saat pengkajian klien sudah habis berapa
plabot infus)
- Metabolisme : ______ ml (Normal: 5 ml/kgBB/hari)
TOTAL : ______ ml
Output :
- Urin : ______ ml (Normal:1500 ml/kgBB/hari) dicari per-jam
- Feses : ______ ml (Normal:100 ml/hari)
- Keringat : ______ ml (Normal:100 ml/hari)
- IWL : ______ ml (Normal:200 ml/kgBB/hari)
- Cairan NGT : ______ ml (Amati jumlah intake yang dimasukkan)

TOTAL : ______ ml

TOTAL : ______ ml
Balance (input – output) : ..............................
Monitoring cairan tiap jam : ..............................

JAM
Minum
Makan
INPUT Infus
Metabolisme
Obat-obatan
 Lain/lain
Urine
Feses
Keringat
OUTPUT IWL
Cairan NGT
Muntah
Lain-lain
Balance cairan Total
(INPUT-
OUTPUT)
D. DATA LABORATORIUM

Tanggal & Jenis Hasil Harga

Satuan Interpretasi
Jam Pemeriksaan Pemeriksaan Normal
E. Analisa Data

No Data Clinical Pathway Etiologi Masalah

F. Diagnosa Keperawatan
1. …………………………………………………………………………….....
2. …………………………………………………………………………….....
3. …………………………………………………………………………….....
4. …………………………………………………………………………….....
5. …………………………………………………………………………….....
 G. RENCANA KEPERAWATAN

Nama Klien : Bangsal :

Umur : No CM :
No Hari/Tgl/Jam Dx. Kep Tujuan dan kriteria hasil Intervensi Rasional Paraf
(1) (2) (3) (4) (5) (6)
 H. IMPLEMENTASI KEPERAWATAN

No.DX Hari/tgl/jam Implementasi Respon Paraf

 I. EVALUASI KEPERAWATAN

No No.DX Hari/tgl/jam Evaluasi Paraf