Lampiran 7 Format Proses Keperawatan KRITIS

PROGRAM STUDI PENDIDIKAN NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

FORMAT PENGKAJIAN KEPERAWATAN KRITIS

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

IDENTITAS
1. Nama Pasien :
2. Umur :
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :

KELUHAN UTAMA
Keluhan utama:………………………………………………………………………………………
……………………………………………………………………………………………………….

RIWAYAT PENYAKIT SEKARANG

1. Riwayat PenyakitSekarang:
………………………………………………………………………………......................................
…………………………………………………………………………………………………………
…..........................................................................................................................................................
…………………………………………………………………………………………………………
…..........................................................................................................................................................

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. Data tambahan:
................................................................................................................................................................
.................................................................................................................................................................
................................................................................................................................................................

RIWAYAT KESEHATAN KELUARGA

Ya tidak
- Jenis :…………………........................................................................
PERILAKU YANG MEMPENGARUHI KESEHATAN
Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak
keterangan…………………….........................................................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olahraga ya tidak
keterangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
a. Keluhan nyeri: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S : Skala nyeri menggunakan CPOT : ...........................

T :...................................................................
2. Sistem Pernafasan (B1)
Jalan Nafas , bebas ya tidak
Obstruksi tidak sebagian total
Benda Asing tidak padat cair
Berupa : …………………..
a. RR:................................
b. Keluhan:: sesak tidak ya nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
a. Sekret:…….. Konsistensi :......................
b. Warna:.......... Bau :..................................
c. Pergerakan dada simetris asimetris
d. Penggunaan otot bantu nafas: tidak ya
e. Jenis:.............................................................................................................................................
f. Irama nafas teratur tidak teratur
g. Pleural Friction rub:.....................................................................................................................
h. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
i. Suara nafas Vesikuler Bronko vesikuler Cracles
Ronki Wheezing
j. Suara perkusi paru sonor hipersonor redup
k. Alat bantu napas ya tidak

Jenis................................................ Flow. ............. lpm

Ventitalor tidak ya
Mode :
FiO2 :
PEEP :
SaO2 :
Vol. Tidal:
I:E Ratio:
Data tambahan:

l. Penggunaan WSD:
- Jenis : ......................................................................................................................
- Jumlah cairan : ......................................................................................................................
- Undulasi :.......................................................................................................

- Tekanan : .......................................................................................................

m. Tracheostomy: ya tidak
........................................................................................................................................................
.......................................................................................................................................................
n. Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
3. Sistem Kardio vaskuler (B2)
Nadi Karotis: teraba tidak
Nadi Perifer: kuat lemah tidak teraba
Perdarahan: ............... cc Lokasi .............
Keluhan nyeri dada: ya tidak
Irama jantung: reguler ireguler
Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
Ictus Cordis:
CRT.............. detik
Turgor normal turun
Akral: hangat kering merah basah pucat dingin

Sikulasi perifer: normal menurun

JVP :.................................

CVP :.................................

CTR :.................................

ECG & Interpretasinya:

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
 ........................................................................................................................................................
........................................................................................................................................................
Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

4. Sistem Persyarafan (B3)

a. GCS : ..................................................
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky oppenheim schaefer
Meningeal Sign kaku kuduk brudzinsky kernig
Lain-lain
d. Keluhan pusing ya tidak

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. Pupil anisokor isokor Diameter: ……/......

g. Tanda PTIK Muntah proyektil nyeri kepala hebat. Lain-lain .....................
h. Curiga Fraktur cervikal jejas atas klavikula multiple trauma, Lain-lain .....................
i. Tanda Fraktur Basis Cranii
Bloody rinorhoe Bloody otorhoe
Brill Hematoma Batle Sign
j. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ........................
k. ICP :................................................
l. Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
.......................................................................................................................................................

5. Sistem perkemihan (B4)

b. Kebersihan genetalia: Bersih Kotor
c. Sekret: Ada Tidak
d. Ulkus: Ada Tidak
e. Kebersihan meatus uretra: Bersih Kotor
f. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

g. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .......................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
h. Produksi urine : ………….. ml/jam
Warna :............…… Bau :......………..
 i. Kandung kemih : Membesar ya tidak
Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
k. Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

6. Sistem pencernaan (B5)

a. TB :............... BB :................................

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, lingkar abdomen ….. cm
Nyeri tekan: ya tidak
Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................

- Warna :...................

- Kondisi area sekitar insersi :...................

h. Peristaltik:.............. x/menit
i. BAB: ...................... x/hari Terakhir tanggal : ..............
j. Konsistensi: keras lunak cair lendir/darah
k. Diet: padat lunak cair
l. Diet Khusus:
........................................................................................................................................................
....................................................................................................
m. Nafsu makan: baik menurun Frekuensi ....... x/hari
Keterangan:
n. Porsi makan: habis tidak .......................
o. Data tambahan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

7. Sistem muskuloskeletal (B6)

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

c. Kelainan ekstremitas: ya tidak

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. Sirkulasi perifer:
............................................. .
i. Kompartemen syndrome ya tidak
j. Kulit: ikterik sianosis kemerahan hiperpigmentasi
k. Turgor baik kurang jelek
l. Luka operasi: ada tidak
Tanggal operasi :................ Jenis operasi :................ Lokasi :................
 Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
m. ROM : ................................................

n. Data tambahan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

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

p. Ekskoriasis: ya tidak
q. Urtikaria: ya tidak
r. Data tambahan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
PEMERIKSAAN RISIKO
JATUH Morse Fall Scale (MSF)
Faktor Risiko Skala Poin Skor Kesimpulan/
Pasien Masalah
Riwayat Jatuh Ya 25
Tidak
Diagnosis Sekunder (≥ Ya
diagnosis medis) Tidak
Alat Bantu Perabot
Tongkat/ Alat Penopang
Tidak Ada/ kursi roda/
perawat/ tirah baring
Terpasang Infus Ya
Tidak
Gaya Berjalan Terganggu
Lemah
Normal/ tirah baring/
imobilisasi
Status Mental Sering lupa akan
keterbatasan yang
dimiliki
Orientasi baik terhadap
kemampuan diri sendiri
Catatan Total

8. Sistem Endokrin
a. Pembesaran tyroid: ya tidak
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak, Nilai:
d. Hiperglikemia: ya tidak, Nilai:
e. Data tambahan:.................. Jelaskan:..................................................

PENGKAJIAN PSIKOSOSIAL
Persepsi klien terhadap penyakitnya:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

Ekspresi klien terhadap penyakitnya

Murung/diam gelisah tegang marah/menangis
Reaksi saat interaksi kooperatif tidak kooperatif curiga
 Gangguan konsep diri:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

Data tambahan:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

PERSONAL HYGIENE & KEBIASAAN

Jelaskan

PENGKAJIAN SPIRITUAL
Kebiasaan beribadah
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

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

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

TERAPI

DATA TAMBAHAN LAIN :

Surabaya, ……………..20...

(………………………)
 PROGRAM STUDI PENDIDIKAN NERS
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA

TANGGAL DATA ETIOLOGI MASALAH

 PROGRAM STUDI PENDIDIKAN NERS
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................
1.
2.
3.
4.
5.
6.
 RENCANA INTERVENSI

HARI/ DIAGNOSA KEPERAWATAN

WAKTU INTERVENSI RASIONAL
TANGGAL (Tujuan, Kriteria Hasil)