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 :
2. Umur:
3. Suku !a
!angsa :
". #gama :
$. Pen%i%ikan :
&. Pekerjaan :
'. #l
#lamat :
(. Sum)e
Sum)err !ia*a
!ia*a :

 KELUHAN UTAMA
1. +elu,an
+elu,an utama:--
utama:-----
------
------
------
------
------
------
------
------
------
----
-
---------------------------------------
-

 RIWAYAT PENYAKIT
PENYAKIT SEKARANG 
SEKARANG 
1. Riwa*at
Riwa*at Pen*ak
Pen*akitSek itSekaraarang:
ng:
------------------------------......................................
----------------------------------------
-..........................................................................................................................................................
----------------------------------------
-..........................................................................................................................................................
----------------------------------------
-..........................................................................................................................................................

 RIWAYAT PENYAKIT
PENYAKIT DAHULU 
1. Perna, %irawat : *a ti%ak kaan :-- %iagnosa :----
2. Riwa*at en*akit kronik %an menular *a ti%ak jenis--------
Riwa*at kontrol : .............................
Riwa*at enggunaan o)at :..............
3. Riwa*a
Riwa*att alerg
alergi:
i:
/)at *a ti%ak jenis--------
Makanan *a ti%ak jenis--------
0ainlain *a
*a ti%ak jenis--------

". Ri
Riwa*at oerasi: *a ti%ak  
 +aan : --------
 Jeni
Jeniss oe
oerrasi : --
--------

$. 0ain
0ainl lai
ain:
n:
................................................................................................................................................................
.................................................................................................................................................................
................................................................................................................................................................

 RIWAYAT KESEHATAN
KESEHATAN KELUARGA
a ti%ak  
 Jeni
Jeniss :---
:-----
--- --...
-.....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....

1
 enogram :

 PERILAKU YANG MEMPENGARUHI KESEHATAN  Masala, +eerawatan :

Perilaku se)elum sakit *ang memengaru,i kese,atan:
#lko,ol *a ti%ak  
keterangan--------.........................................................
Merokok *a ti%ak  
keterangan--------.........................................................
/)at *a ti%ak  
keterangan-..............................................................------
/la,raga *a ti%ak  
keterangan-..........................................................-------

OBSERVASI DAN PEMERIKSAAN FISIK 

1. Tanda tanda vital
S: N: T: RR :
+esa%aran 4omos Mentis #atis Somnolen Soor +oma

2. Sit!" P!#na$aan %B1&

a. RR:................................
 ). +elu,an: sesak n*eri waktu na5as ort,onea
!atuk ro%ukti5 ti%ak ro%ukti5  
Sekret:--.. +onsistensi :......................
6arna:.......... !au :..................................
7. Penggunaan otot )antu na5as:
........................................................................................................................................................
.......................................................................................................................................................
%. 8rama na5as teratur ti%ak teratur  
e. Pleural 9ri7tion ru):.....................................................................................................................
5. Pola na5as Disnoe +usmaul 4,e*ne Stokes !iot
g. Suara na5as 4ra7les Ronki 6,eeing
,. #lat )antu naas *a ti%ak  

Jenis................................................ 9low..............lm

;entitalor 
 Mo%e :
9i/2 :
 P<<P :
Sa/2 :
;ol. Ti%al:
8:< Ratio:
0ainlain :

i. Penggunaan 6SD:
 Jenis : ......................................................................................................................
2
  Jumla, 7airan : ......................................................................................................................
 Un%ulasi :......................................................................................................................
 Tekanan : ......................................................................................................................
 j. Tra7,eostom*: *a ti%ak 
........................................................................................................................................................
.......................................................................................................................................................
k. 0ainlain:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

'. Sit!" Ka#di( va)*l!# %B2&

a. +elu,an
Masala, +eerawatann*eri %a%a:: *a ti%ak  
P :...................................................................
= :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
 ). 8rama jantung: reguler ireguler 
7. Suara jantung: normal >S1S2 tunggal? murmur  
gallo lainlain.....
%. 87tus 4or%is: ..................................................................................................................................
e. 4RT :.............%etik 
5. #kral: ,angat kering mera, )asa, u7at
 anas %ingin
g. Sikulasi eri5er: normal menurun
,. J;P :.................................
i. 4;P :.................................
 j. 4TR :.................................
k. <4 @ 8nterretasin*a:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
l. 0ainlain :
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

+. Sit!" P!#,a#a$an %B'&

a. 4S : .................................................. Masala, +eerawatan :
 ). Re5leks 5isiologis atella tri7es )i7es
7. Re5leks atologis )a)insk* )ru%insk* kernig
0ainlain
%. +elu,an using *a ti%ak  
P :...................................................................
= :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

e. Pemeriksaan sara5 kranial:

 N1 : normal ti%ak +et.: --..............................................................
 N2 : normal ti%ak +et.: --..............................................................
 N3 : normal ti%ak +et.: --..............................................................
 N" : normal ti%ak +et.: --..............................................................
 N$ : normal ti%ak +et.: --..............................................................
 N& : normal ti%ak +et.: --..............................................................
 N' : normal ti%ak +et.: --..............................................................
 N( : normal ti%ak +et.: --..............................................................
 NA : normal ti%ak +et.: --..............................................................

3
  N1B : normal ti%ak +et.: --..............................................................
 N11 : normal ti%ak +et.: --..............................................................
 N12 : normal ti%ak +et.: --..............................................................

5. Ho55manTromer test :
g. Puil anisokor isokor Diameter: --......
,. S7lera anikterus ikterus
i. +onjun7tiCa ananemis anemis
 j. 8sitra,atTi%ur :................. JamHari angguan ti%ur : ........................
k. 8;D :................................................
l. <;D :................................................
m. 84P :................................................
n. 0ainlain:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
.......................................................................................................................................................
o. Tan%aTan%a PT8+:
 . angguan en%engaran: #%a Ti%ak  Jelaskan:
E. angguan engli,atan : #%a Ti%ak Jelaskan:
  r. angguan Pen7iuman F #%a Ti%ak Jelaskan

-. Sit!" !#)!"i/an %B+&

Masala, +eerawatan
a. +e)ersi,angenetalia: !ersi, +otor 
 ). Sekret: #%a Ti%ak 
7. Ulkus: #%a Ti%ak  
%. +e)ersi,an meatus uretra: !ersi, +otor 
e. +elu,an ken7ing: #%a Ti%ak  
!ila a%a jelaskan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

5. +emamuan )erkemi,:
Sontan #lat )antu se)utkan: .......................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Pro%uksi urine : ----.. mljam
6arna :............--
!au :......---..
,. +an%ung kemi, : Mem)esar *a ti%ak  
i. N*eri tekan *a ti%ak  
 j. 8ntake 7airan oral : --- 77,ari arenteral : --- 77,ari
k. !alan7e 7airan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
o. 0ainlain:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

0. Sit!" !n!#naan %B-&

a. T! :............... !! :................................ Masala, +eerawatan :
 ). 8MT :............... 8nterretasi :................................
7. 0/0# :...............

%. Mulut: )ersi, kotor )er)au

e. Mem)ran mukosa: lem)a) kering stomatitis
5. Tenggorokan:
sakit menelan kesulitan menelan

"
  em)esaran tonsil n*eri tekan
g. #)%omen: tegang kem)ung as7ites
,. N*eri tekan: *a ti%ak  
i. 0uka oerasi: a%a ti%ak
Tanggal oerasi :................
Jenis oerasi :................
0okasi :................
+ea%aan :................
Drain : a%a ti%ak
 Jumla, :...................
 6arna :...................
 +on%isi area sekitar insersi :...................
 j. Peristaltik:.............. Gmenit
k. !#!: ......................G,ari Terak,ir tanggal : ..............
l. +onsistensi: keras lunak 7air len%ir%ara,
m. Diet: a%at lunak 7air  
n. Diet +,usus:
........................................................................................................................................................
....................................................................................................
o. Na5su makan: )aik menurun 9rekuensi:.......G,ari
 . Porsi makan: ,a)is ti%ak +eterangan:.......................
E. 0ainlain:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

. Sit!" "*)*l()!l!tal %B0&

a. Pergerakan sen%i: )e)as ter)atas
 ). +ekuatan otot:

7. +elainan ekstremitas: *a ti%ak  

Masala, +eerawatan :
%. +elainan tulang )elakang: *a ti%ak 
9rankel: ................................................................................
e. 9raktur: *a ti%ak  
 Jenis :...................
5. Traksi: *a ti%ak  
 Jenis :...................
 !e)an :...................
 0ama emasangan :...................
g. Penggunaan salkgis: *a ti%ak  
,. +elu,an n*eri: *a ti%ak 
P :...................................................................
= :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
i. Sirkulasi eri5er: ..............................................
 j. +omartemen s*n%rome *a ti%ak 
k. +ulit:ikterik sianosis kemera,an ,ierigmentasi
l. Turgor )aik kurang jelek  
m. 0uka oerasi: a%a ti%ak
Tanggal oerasi :................
Jenis oerasi :................
0okasi :................
+ea%aan :................
Drain : a%a ti%ak
 Jumla, :...................
 6arna :...................
 +on%isi area sekitar insersi :...................
n. R/M : ................................................

o. 0ainlain:

$
 .......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

 . Pitting e%ema:  gra%e:................

E. <kskoriasis: *a ti%ak  
Masala, +eerawatan :
r. Urtikaria: *a ti%ak  
s. 0ainlain:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

3. Sit!" End()#in
a. Pem)esaran t*roi%: *a ti%ak   Masala, +eerawatan :
 ). Pem)esaran kelenjar geta, )ening: *a ti%ak 
7. Hioglikemia: *a ti%ak  
%. Hierglikemia: *a ti%ak  
e. 0ainlain:..................Jelaskan:..................................................

 PENGKAJIAN PSIKOSOSIAL Masala, keerawatan :

5. Persesi klien ter,a%a en*akitn*a:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

g. <ksresi klien ter,a%a en*akitn*a

Murung%iam gelisa, tegang mara,menangis
,. Reaksi saat interaksi kooerati5 ti%ak kooerati5 7uriga
i. angguan konse %iri:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

 j. 0ainlain:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

 PERSONAL HYGIENE & KEBIASAAN 

Masala, +eerawatan :

Jelaskan

 PENGKAJIAN SPIRITUAL
a. +e)iasaan )eri)a%a, Masala, +eerawatan :
- Se)elum sakit sering ka%ang ka%ang ti%ak erna,
- Selama sakit sering ka%ang ka%ang ti%ak erna,

 ). !antuan *ang %ierlukan klien untuk memenu,i ke)utu,an )eri)a%a,:

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

&
 PEMERIKSAAN PENUNJANG %La4(#at(#i*"5Radi(l(6i5 EKG5 USG 5 dll&

TERAPI

DATA TAMBA7AN LAIN 8

Sura)a*a -----..2B...

%999999999&

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 PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA

TANGGAL DATA ETIOLOGI MASALA7

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 PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL8 .................................
1.
2.
'.
+.
-.
0.

A
 REN:ANA INTERVENSI

7ARI; DIAGNOSA KEPERAWATAN

WAKTU INTERVENSI RASIONAL
TANGGAL %T*<*an5 K#it!#ia 7ail&

1B

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

7a#i;T6l;S/i$t N(. DK   Ja" I"l!"!ntai Pa#a$ Ja" Eval*ai %SOAP& Pa#a$  

11
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

7a#i;T6l;S/i$t N(. DK   Ja" I"l!"!ntai Pa#a$ Ja" Eval*ai %SOAP& Pa#a$  

11
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