BAGIAN KGD FORMAT PENGKAJIAN KEPERAWATAN KRITIS

STIKes WN
I. Identitas Mahasiswa
Nama MHS :
NIM :
Kelompok :
Tgl Praktek :

II. Identitas Klien

Nama : ............................................ Umur : ..............................
No. MR : ............................................ Jenis Kelamin :
.............................. Tanggal : ............................................ Hari rawat ke
: .............................. Agama : ............................................ Status
: .............................. Alergi : ............................................ Berat badan
: .............................. Alamat Rumah
: ......................................................................................................... Diagosa Medis
: .........................................................................................................

III. Alasan dirawat di ICU

Klien demam dan kejang..Tidak sadar
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IV. Pengkajian Fisik Dan Pengkajian Umum

Kardiovaskuler Muskuloskeletal
Normal Normal

Dx. Kep: Dx. Kep:

Pernafasan Genitourinaria
Normal Normal

Dx. Kep: Ansietas Dx. Kep:

Neurologis dan Sensori Integumen

demam dan sempat mengalami Normal
kejang

Dx. Kep: Dx. Kep:

BAGIAN KGD FORMAT PENGKAJIAN KEPERAWATAN KRITIS
STIKes WN
Gastrointestinal Endokrin
Normal Normal
 Dx. Kep: GG kebutuhan Nutrisi Dx. Kep:

Nutrisi Klien Psikososial

muntah ± 5 kali, tidak mau makan
dan malas minum, dan muntah

Dx. Kep: Dx. Kep:

Cairan Istirahat Tidur

Dx. Kep: Dx. Kep:

V. Monitoring Tiap Jam

6 7 8 9 10 11 12 13 14
H 40
E
M
O
D
39
I
N
A
M
I
K 38

37

36

35
Kesadaran
Irama EKG
Nyeri
CVP

Resp Tipe Vent

PEEP/
CPAP
RR
TV
 Neuro Mata
Ukuran
Reaksi
Kaki
Tangan
GCS
Input Line 1

Line 2

Line 3

Line 4

Enteral

Total
Output NGT
Urine
BAB
Drain
Total

VI. Terapi/Program Medis

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VII. Hasil Uji Diagnostik
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Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan :

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 BAGIAN KGD FORMAT PENGKAJIAN KEPERAWATAN GAW AT DARURAT
STIKes WN
I. Identitas Mahasiswa
Nama MHS :
NIM :
Kelompok :
Tgl Praktek :

II. IDENTITAS KLIEN

NAMA KLIEN :
USIA/TGL LAHIR :
JENIS KELAMIN :
TANGGAL MASUK :
NO REGISTER :
DIAGNOSA MEDIK :

TRIAGE: P1 P2 P3 P4

III. KELUHAN UTAMA ALASAN MASUK RS

P : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
Q : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
R : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
S : ………………………………………………………………………………………………..
………………………………………………………………………………………………..
T : ………………………………………………………………………………………………..
………………………………………………………………………………………………..

IV. PENGKAJIAN PRIMER

AIRWAY
SUMBATAN:
Jalan Nafas : Paten Tidak Paten
Obstruksi : Lidah Cairan Benda Asing T/A
Suara Nafas : Snoring/mdgkr Gurgling/brdenguk Stridor /berisik sep angin T/A
Perhatian : Cedera servikal

BREATHING
Sesak, dengan :
Aktifitas ....................................................................................
Tanpa aktifitas .........................................................................
Nafas cuping hidung ...............................................................
Menggunakan otot tambahan .................................................
Frekuensi
Irama:
Teratur .....................................................................................
Tidak teratur ............................................................................
Kedalaman
Dalam ..................................................................................
Dangkal ................................................................................
Cepat ....................................................................................
Batuk:
Produktif ...............................................................................
Non produktif ........................................................................
 Bunyi nafas tambahan:
Ronkhi ..................................................................................
Crackles/celah,retak ............................................................
Wheezing/Mencuit2 ..............................................................

CIRCULATION
Kesadaran : .............................................................................
Sirkulasi perifer : .......................................................................
Nadi : ........................
Irama :........................
Teratur /Tidak teratur : .........................................................
Denyut:
Lemah ..................................................................................
Kuat .....................................................................................
Tidak kuat .............
Tekanan darah :.........
Ekstremitas : ..............
Hangat ..................
Dingin ..................
Warna kulit :
Cyanosis ..............
Pucat ....................
Kemerahan ...........

DISABILITY
Pemeriksaan neurologis singkat
Respon:
Alert/perhatian ......................................................................
Voice respons/respon terhadap suara .................................
Pain respons/respon terhadap nyeri .....................................
Unresponsive/tidak berespon ...............................................
Reaksi pupil ..........................................................................

EKSPOSURE/ENVIRONMENT/EVENT
Deformitas : Ya Tidak
Contusio : Ya Tidak
Abrasi : Ya Tidak
Penetrasi : Ya Tidak
Laserasi : Ya Tidak
Edema : Ya Tidak
Keluhan Lain:
…………..…………………………………………………………..
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V. PENGKAJIAN SEKUNDER
Riwayat kesehatan sekarang ....................................................
Riwayat kesehatan keluarga ....................................................
Anamnesa singkat (AMPLE) ......................................................
Allergies.............................
Medikasi ............................
Nyeri ..................................
Terakhir kali makan ...........
Event of injury/penyebab injury..........

Pemeriksaan head to toe

- Kepala
Rambut :
- Mata :

- Telinga :
 - Hidung :

- Mulut :

- Leher
Deviasi/simetns, cedera servikal ..........................................
Kelenjar tiroid .......................................................................
Kelenjar limfe .......................................................................
Trakea ..................................................................................
JVP .......................................................................................

- Dada
I :

P :

P :

A :

- Abdomen :
I :

A :

P :

P :

- Ekstermitas/musculoskeletal
Rentang gerak.................................................................
Kekuatan otot ..................................................................
Deformitas.......................................................................
Kontraktur .......................................................................
Edema ............................................................................
Nyeri................................................................................
Krepitasi ..........................................................................

- Kulit/integumen:
Turgor:
Baik .................
Buruk ..............
Sedang ...........
Mukosa:
Lembab ...........
Kering..............
Kulit:
Bintik merah ...
Lesi .................
Suhu .....................

VI. PEMERIKSAAN PENUNJANG

Pemeriksaan Radiologi :

Pemeriksaan Lab darah :

Pemeriksaan Penunjang lainnya :

VII. TERAPI MEDIS

Tanggal Pengkajian : TANDA TANGAN PENGKAJI:

Jam :
Keterangan :

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