PROGRAM STUDI PENDIDIKAN NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

PENGALAMAN BELAJAR PRAKTIKA

FORMAT PENGKAJIAN KEPERAWATAN KRITIS

Tanggal MRS : Jam Masuk :

Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :
Hari rawat ke :

IDENTITAS
1. Nama Pasien : NY.R
2. Umur : 41
3. Suku/ Bangsa : indonesia
4. Agama : islam
5. Pendidikan : SMA
6. Pekerjaan : IRT
7. Alamat :
8. Sumber Biaya :

KELUHAN UTAMA
1. Keluhan utama: Pasien mengatakan sesak nafas

RIWAYAT PENYAKIT SEKARANG

Ny R mengeluh sesak nafas sejak dini hari dan mengalami penurunan kesadaran lalu
dibawa keluarga ke IGD pukul 04.30. Klien sebelumnya sudah pernah dirawat di
Rumah Sakit dengan riwayat jantung. Setelah mendapat pertolongan pertama, Ny R
dibawa ke ICU pada pukul 05.50 WIB dan dipasang ventilator selama 2 hari.

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: 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:
Alkohol ya tidak
keterangan…………………….........................................................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olahraga ya tidak
Keterangan : Terkadang jalan sehat

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S : 36,6 N : 80x/m T : 150/100 mmHg RR : 28x/m
Kesadaran Compos Mentis Apatis Somnolen Sopor
Koma

2. 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:
..............................................................................................................................
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3. Sistem Kardio vaskuler (B2)

a. Keluhan
Masalah Keperawatan nyeri: dada: ya tidak
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 : >2 detik
f. Akral: hangat kering merah basah pucat
panas dingin
g. Sikulasi perifer: normal menurun
h. JVP :.................................
i. CVP :.................................
j. CTR :.................................
k. ECG & Interpretasinya:
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 ..............................................................................................................................
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l. Lain-lain :
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4. Sistem Persyarafan (B3)

a. GCS : .................................................. 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.:
……..............................................................
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 :................. Jam/Hari Gangguan tidur : ........................
k. IVD :................................................
l. EVD :................................................
m. ICP :................................................
n. Lain-lain:
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
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.......................................................................................................
o. Tanda-Tanda PTIK:
p. Gangguan pendengaran: Ada Tidak , Jelaskan: normal
q. Gangguan penglihatan : Ada Tidak, Jelaskan: normal
r. Gangguan Penciuman ; Ada Tidak, Jelaskan: normal

5. Sistem perkemihan (B4) Masalah Keperawatan

a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
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....
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:
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o. Lain-lain:
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6. Sistem pencernaan (B5)
a. TB :............... BB :................................ Masalah Keperawatan :
b. IMT :............... Interpretasi :................................
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:.............. x/menit
k. BAB: 2 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:
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7. Sistem muskuloskeletal (B6)

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

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 :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : ................................................

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

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

q. Ekskoriasis: ya tidak Masalah Keperawatan :
r. Urtikaria: ya tidak
s. Lain-lain:
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8. Sistem Endokrin
Masalah Keperawatan :
a. Pembesaran tyroid: ya tidak
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:
Klien yakin jika penyakit yang dialaminya akan cepat sembuh.

g. Ekspresi klien terhadap penyakitnya

Murung/diam gelisah tegang marah/menangis
h. Reaksi saat interaksi kooperatif tidak kooperatif curiga
i. Gangguan konsep diri:
...............................................................................................................................
...............................................................................................................................
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j. Lain-lain:
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 ...............................................................................................................................

PERSONAL HYGIENE & KEBIASAAN Masalah Keperawatan :

Jelaskan
Biasanya ketika diruma klien selalu mandi melakukan personal hygiene
dengan mandiri, tetapi ketika di RS semua dibantu oleh perawat.

PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak
pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

Klien perlu bimbingan saat akan melakukan ibadah, karena kondisi lemah jadi
tidak bisa melakukan dengan mandiri.

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

TERAPI

DATA TAMBAHAN LAIN :

Surabaya, ……………..20...

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