Prodi Pendidikan Profesi Ners

Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KRITIS

PRODI SARJANA TERAPAN KEPERAWATAN PROGRAM PROFESI NERS
JURUSAN KEPERAWATAN POLTEKKES KEMENKES BENGKULU

Tanggal Pengkajian : Tanggal Masuk :

Ruang Kelas : Nomor Register :
Diagnose Medis :

A. IDENTITAS KLIEN
Nama Klien :

Jenis Kelamin :
Usia/Tanggal lahir :
Status perkawinan :
Agama :
Suku Bangsa :
Pendidikan :
Bahasa yang digunakan :

Pekerjaan :
Alamat :
Nama Penanggung Jawab :
Alamat Penanggung Jawab :

B. KELUHAN UTAMA MRS

1. Keluhan Utama Masuk Rumah Sakit
Hari/Tanggal/Jam MRS : / /

2. Keluhan Utama dan Kronologi Masuk ruang HCU/ICU/ICCU

Hari/Tanggal/Jam Masuk HCU/ICU/ICCU: / /

3. Penanganan yang telah dilakukan

 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

(sebelum masuk HCU/ICU/ICCU, saat masuk RS atau saat diruangan lain)

C. PENGKAJIAN PRIMER KEPERAWATAN KRITIS

Hari/Tanggal/Jam Pengkajian : / /
Keadaan Umum :
Keluhan saat dikaji :

(Keluhan, Penggunaan alat, Pemeriksaan fisik, Pemeriksaan penunjang )

(A) Airway .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
(B) Breathing .....................................................................................................................
Jika menggunakan .....................................................................................................................
ventilator jelaskan .....................................................................................................................
mode yang .....................................................................................................................
digunakan .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

(C) Circulation .....................................................................................................................

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

(D) Disability Pengkajian Kesadaran

Skor GCS : Eyes ................. Verbal ............... Motorik .......................
Kesadaran :
Pupil, Ukuran Kiri ................... Ukuran kanan ....................
Reflek cahaya ............../..................
Motorik / Sensori :
Pengkajian Nyeri :
Verbal :
P : ...............................................................................................................
Q : ...............................................................................................................
R : ...............................................................................................................
S : ...............................................................................................................
Lampirkan instrumen T : ...............................................................................................................
CPOT, Braden Scale, Non Verbal :
Morse Scale, RASS Score CPOT : ........................................................................................
Pengkajian resiko dekubitus
Score Braden Scale : .............................................................................
Pengkajian resiko jatuh
Score Morse scale : ...............................................................................
Pengkajian manajemen Sedasi :
Pengkajian sadasi : ...............................................................................
Score RASS : ...............................................................................
(E) Elimination Intake (Sebelumnya) Output ( sebelumnya)
Parental : ......................... cc Urine : ............................. cc
Med. Drip : ......................... cc IWL : ............................. cc
Oral/NGT : ......................... cc Drain : ............................. cc
Jumlah : ..........................cc Muntah : ............................ cc
BAB : ............................ cc
Jumlah : .............................. cc

Balance cairan : In ................... – Out ................. = ................... cc

Hitung Kebutuhan cairan aktual :

Status Nutrisi :
Berat Badan : ............ Kg Tinggi Badan : ............ cm IMT:.........kg/cm
Hitung Kebutuhan Nutrisi actual :
 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

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

D. PEMERIKSAAN FISIK
(Inspeksi, Auskultasi, Palpasi, Perkusi, Olfaksi)
Kepala & Leher .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Dada .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Abdomen .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

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

Genetalia .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Ektremitas .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

E. PEMERIKSAAN PENUNJANG
1. Laboratorium
Pemeriksaan Nilai Normal Satuan Hasil Tanggal
Pemeriksaan Pemeriksaan
Hematologi
Hemoglobin
Hematoktit
Eritrosit
Leukosit
Trombosit
LED
MCV
MCH
MCHC
Waktu protrombin
PPT control
Waktu tromboplastin
Kimia Klinik
Fungsi Hati
Bilirubin total
Bilirubin indirect
Bilirubin direct
Albumin
Globulin
SGOT/AST
SGPT/ALT
Fungsi Ginjal
Ureum
Creatinin
Asam Urat
Fungsi Jantung
CPK
CK-MB
LDH
Fungsi metabolisme KH
GDS
 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

GD Puasa
GD PP
HBA 1C
Fungsi Pankreas
Lipase
Amilase
L iron
TIBC
Elektrolit
Natrium
Kalium
Chlorida
Kalsium
Phospor
Profila Lipid
Kolestreol total
HDL
LDL
Trigliserida

Analisa Gas Darah

pH
pCO2
pO2
HCO3
AADO2
Laktat
Base Exces

Pemeriksaan Penunjang (Radiologi, CT Scan, Endoskopi, Histopatologi, dll)

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
...........................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
...........................................................................................................................................................
Penatalaksanaan Kolaborasi Terapi Medis :
............................................................................................................................................................
............................................................................................................................................................
 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

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

ANALISA DATA
NAMA PASIEN : …………………… UMUR :…………………….
RUANGAN : …………………… NO.REG :………………….

NO DATA SENJANG ETIOLOGI MASALAH

 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

DAFTAR DIAGNOSA KEPERAWATAN KRITIS BERDASARKAN PRIORITAS

.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
 Prodi Pendidikan Profesi Ners
Jurusan keperawatan
Poltekkes Kemenkes Bengkulu

...........................................................................................................................................................................
...........................................................................................................................................................................
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................................................
 PERENCANAAN KEPERAWATAN

NAMA PASIEN :…………………………… UMUR : …………………………….

RUANGAN :…………………………… NO.REG : ……………………………

NO DIAGNOSA KEPERAWATAN
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
RENCANA TINDAKAN KEPERAWATAN
TUJUAN /KRITERIA HASIL INTERVENSIKEPERAWATAN RASIONAL
(NOC) (NIC)
Setelah dilakukan intervensi keperawatan
selama ........... x jam, diharapkan pasien :
Aktivitas ..................................................................
............................................................................. Keperawatan : ............................................................... ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
............................................................................. ........................................................................................ ..................................................................
.........................
..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................
........................................................................................ ..................................................................

NO DIAGNOSA KEPERAWATAN
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...............................................................
...........................................................
RENCANA TINDAKAN KEPERAWATAN
TUJUAN /KRITERIA HASIL INTERVENSI KEPERAWATAN RASIONAL
(NOC) (NIC)
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
..................................................................... ................................................................................ .......................................................................
................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ .......................................................................
............................................................................. ................................................................................ ...................................................................
............................................................................. ................................................................................
............................................................................. ...............................................................................
.............................................................................
......
CATATAN PERKEMBANGAN KEPERAWATAN KRITIS TERINTEGRASI
 NAMA PASIEN :…………………………… UMUR : …………………………….
RUANGAN :…………………………… HARI KE : ……………………………

SOAP AWAL SHIFT ............... S-O-A-P SELESAI SHIFT ..............................

Subjektif & Objektif Subjektif & Objektif
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
 Airway  Airway
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
 Breathing  Breathing
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
 Circulation ……………………………………………………………………………………  Circulation ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
 …………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
 Disability  Disability
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …

…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
 Eliminasi …  Eliminasi …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …

Analisis …………………………………………………………………………………… Analisis ……………………………………………………………………………………

… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
 …………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …

…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
Planning … Planning …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
…………………………………………………………………………………… ……………………………………………………………………………………
… …
 LEMBAR IMPLEMENTASI DAN MONITORING KEPERAWATAN KRITIS
PRODI SARJANA TERAPAN KEPERAWATAN PROGRAM PROFESI NERS
JURUSA KEPERAWATAN POLTEKKES KEMNEKS BENGKULU

Nama Pasien : Usia :

Diagnosa Medis : Hari/Tanggal :

Pukul
Tekanan Darah
Frek. Nadi
Frek. Nafas
HEMODINAMIK

Suhu
Kesadaran
Irama EKG
CPOT
CVP
SaO2
Mode Ventilator
RESPIRASI

PEEP/CPAP
RR
TV
FiO2
pH
pCO2
AGD

HCO3
SaO2
BE
Ukuran Pupil
Reaksi cahaya
NEURO

Kaki
Tangan
GCS
Parental
INPUT

Med. Drip

Oral/NGT

Urine

BAB
OUTPUT

IWL

Drain

Muntah

Aktifitas keperawatan yang dilakukan :

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