PANDUAN PENGERJAAN KASUS KRITIS

1. Silahkan membagi kelas menjadi 6 kelompok

2. Kelompok 1, 2 dan 3 mengerjakan kasus 1
Kelompok 4,5 dan 6 mengerjakan kasus 2
3. Setiap kelompok mengerjakan kedua kasus sesuai dengan format askep yang
diberikan dengan minimal 2 diagnosa sesuai 3S
4. Format pengumpulan tugas:
a. Cover
b. Kasus
c. Asuhan Keperawatan
5. Penugasan dikumpulkan maksimal Jumat, 30 Desember 2022 jam 12.00 WIB

Kasus 1

Wanita usia 42 tahun dengan no MR 0157512 pekerjaan petani sedang dirawat di ICU.
Klien masuk melalui rujukan dari RSU Setia dengan keluhan sesak napas disertai batuk
berdashak, nyeri ulu hati disertai mual dan muntah .
Dari hasil pengkajian saat ini terdengar suara berkumur dan buih putih kekuningan dari
mulut. Klien Nampak sesak, RR 46x/menit,SpO2 68%, tampak pernapasan cuping hidung
dan otot bantu pernapasan, napas cepat cepat dan cepat. TD 140/112mmHg, HR
138x/menit, suhu 36,5 derajat, akral dingin, CRT >3 detik, GCS 8. Diketahui GDS 316
mg/dl, IVFD terpasang NaCl 0,9% 60cc/jam, drip insulin 50 unit dalam 50cc NaCl 0,9%
habis dalam 12 jam dengan tetesan 8,3cc/jam via infus pump, terpasang NRM
10l/menit, Sp02 68%.
Klien memiliki riwayat HT dan DM idak terkontrol yang terdeteksi sejak 2tahun yang lalu.

Kasus 2
Laki-laki usia 70 tahun pekerjaan tani no RM 340346. Klien dibawa ke IGD karena
mengalami penurunan kesadaran, keluar keringat dingin, badan lemas, ekstremitas kiri
lemah baik atas maupun bawah.. Kemudian klien dibawa ke ruang ICU untuk
mendapatkan perawatan intensive. Nampak pengembangan dada kanan kiri sama, tidak
ada bekas luka serta tidak Nampak retraksi dinding dada, perfusi sonor, sedangkan dari
auskultasi terdapat suara ronchi. Dari mulut Nampak secret berwarna putih.
Pemeriksaan jantung menunjukkan ictus cordis tidak nampak terdengar S1 S2 reguler.
Saat ini kesadaran somnolent E3V1M4, terpasang infuse RL 20 tpm, terpasang DC,
terpasang O2 nasal 3 lpm. Dengan TD : 190/110 mmHg, N: 106x/mnt, RR : 26x/mnt, S :
36,5°C.
Klien mendapatkan terapi infuse RL 20 tpm, O2 nasal 3 lpm, injeksi ceftriaxone 1 gram,
injeksi ranitidine 25 mg. Klien terpasang NGT, DC, dan infuse.
Hasil pemeriksaan labolatorium pada tanggal 11 Juli 2012 diperoleh hasil: nilai
Hemoglobin 14,1 gr/dl (13-16), Leokosit 19,5 ribu/ul (4-12 ribu/ul), Eritrosit 43,81
juta/ul, Hematokrit 39,9 % (36-47 %), Trombosit 447 ribu/ul (150-400 ribu/ul), Kreatinin
1,3 mg/dl, Ureum 35,3 mg/dl.
PENGKAJIAN KEPERAWATAN KRITIS

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 PROGRAM STUDI PROFESI NERS
UNIVERSITAS dr. SOEBANDI JEMBER
Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :

A. IDENTITAS DIRI KLIEN

Tanggal/jam MRS :.....................................................
Diagnosa Medis :.....................................................
Tgl/jam pengkajian :.....................................................
Inisial Nama Pasien : …………………………………. Suami/istri/ orang tua
Usia : …………………………………. Nama :........................
Jenis Kelamin : ………………………………….
Pekerjaan :.......................
Agama : ………………………………….
Suku/Bangsa :...................................................... Alamat :.......................

Bahasa :......................................................
Status : ………………………………….
Penanggung Jawab
Pendidikan :......................................................
Pekerjaan : …………………………………. Nama :......................

Alamat : …………………………………. Alamat :......................

B. KELUHAN UTAMA SAAT MASUK RUMAH SAKIT:

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KLASIFIKASI KESEIMBANGAN ASAM BASA :

C. Riwayat Alergi Obat :

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D. Nyeri (Vas Scale) :

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 Durasi Nyeri :

Ringan: 1-3, Sedang: 4-6, Berat: 7-10

E. RIWAYAT PENYAKIT DAHULU

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F. RESIKO JATUH (Morse Scale)

Resiko Jatuh (Morse Scale) √ (Cheklist) Skor
pada kotak skor
Riwayat Jatuh yang baru atau dalam 3 Tidak 0=
bulan terakhir Ya 25=
Diagnosis medis sekunder >1 Tidak 15=
Ya 0=
Alat bantu jalan Bed rest 0=
Penompang tongkat 15=

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 Furnitur 30=
Memakai terapi heparin lock/iv Tidak 0=
Ya 20=
Cara berjalan/ Berpindah Normal/bedrest/imobilisasi 0=
Lemah 10=
Terganggu 20=
Status mental Orientasi sesuai kemampuan 0=

Lupa keterbatasan 15==

Kesimpulan : 0-24 (tidak berisiko), >24-45 (risiko sedang), >45 (risiko tinggi)
Skor Total: ....................

G. PENGKAJIAN KEPERAWATAN
1. Persepsi dan pemeliharaan kesehatan (Pengetahuan tentang penyakit/
perawatan; obat yang biasa dikonsumsi, faktor risiko tentang penyakit,
seperti: riwayat keluarga, kebiasaan, dll.; perlindungan kesehatan;
kebiasaan dalam menangani sakit, seperti: pilihan pengobatan; kebutuhan
akan edukasi kesehatan/ discharge planning)
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2. Pola Nutrisi dan Metabolismenya

Program diit RS : _____________________________________________
Intake makanan (Pengkajiam nutrisi ABCD/ skrining nutrisi; faktor
spesifik dalam memilih makanan, seperti: budaya, agama, ekonomi; faktor
yang mempengaruhi ingesti makanan, seperti: nafsu makan, kenyamanan,
kesehatan gigi dan mulut, alergi, nyeri, mual, muntah, pantangan
makanan):

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Intake cairan : _____________________________________________

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3. Pola eliminasi
a. Buang Air Besar (frekuensi, warna, jumlah, konsistensi,
ketidaknyamanan, kontrol saat defekasi, apakah ada perubahan
khusus)
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b. Buang Air Kecil (frekuensi, warna, jumlah, bau, ketidaknyamanan,
kontrol saat defekasi, apakah ada perubahan khusus, nokturia)
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c. Balance Cairan
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4. Pola Aktivitas dan latihan

Kemampuan Perawatan diri 0 1 2 3 4
Makan dan minum
Mandi
Toileting
Berpakaian
Mobilitas ditempat tidur
Berpindah
Ambulansi/ROM
Keterangan : 0: Mandiri, 1 : alat bantu, 2 : dibantu orang lain, 3: dibantu
orang lain dan alat, 4: tergantung total
a. Skor Pengkajian Fungsional ADL (BARTHEL INDEX):
b. Skor Risiko Jatuh (MORSE):
c. Skor Risiko Dekubitus (BRADEN SCALE):
d. Fungsi Respiratory:
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e. Fungsi Cardiovascular:
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5. Pola Tidur dan Istirahat (lama tidur, gangguan tidur; penggunaan obat bantu
tidur; faktor terkait, seperti nyeri, kenyamanan lingkungan, suhu):

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6. Pola Perceptual (penglihatan; pendengaran; pengecap; sensasi; pembau;
penggunaan alat bantu; nyeri dan kenyamanan):
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7. Pola persepsi diri (pandangan klien tentang sakitnya; kecemasan; konsep
diri):
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8. Pola Seksualitas dan Reproduksi (masalah seksual; fertilitas, libido,
menstruasi, kontrasepsi, dll.):
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9. Pola Peran-hubungan (perubahan peran, komunikasi, hubungan dengan orang
lain, kemampuan keuangan, significant others):
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10. Pola Managemen Koping-Stress (stress saat ini; koping; perubahan terbesar
dalam hidup pada akhir-akhir ini/ kehilangan, dll):
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11. Sistem Nilai dan Keyakinan (budaya terkait kesehatan; pandangan klien
tentang agama; kegiatan agama, dll.):
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H. PEMERIKSAAN FISIK
1. Kelulahan yang dirasakan saat ini:
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2. Pemeriksaan Umum (TTV Dasar)

a. Kesadaran : ……………………………
b. GCS : ……………………………
c. Suhu : …………………………… OC
d. Nadi : …………………………… x/menit
e. Tekanan Darah : …………………………… mmHg
f. RR : …………………………… x/menit

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 g. BB/ TB: _________ kg/ __________ cm

3. Pemeriksaan Kepala
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4. Pemeriksaan Leher
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5. Pemeriksaan Thoraks
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6. Pemeriksaan Abdomen
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7. Pemeriksaan Kelamin dan Anus

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8. Ekstremitas:
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9. Pemeriksaan Neurologi
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I. HASIL PEMERIKSAAN PENUNJANG

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 1. Laboratorium
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2. Foto Rongen/USG/ECG/dll
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J. PENATALAKSANAAN DAN TERAPI

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............, ………………………20
Pemeriksa,

(…………………………………………)

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 ANALISA DATA
TGL/ Data Masalah Penyebab
JAM

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DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN
PRIORITAS
NO PRIORITAS DIAGNOSA KEPERAWATAN
1.

2.

3.

4.

Dst

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 RENCANA INTERVENSI KEPERAWATAN
DIAGNOSA
INDIKATOR URAIAN
KEPERAWATAN
SERTA SKOR AWAL AKTIVITAS
NO TANGGAL DITEGAKKAN /
DAN SKOR TARGET RENCANA
KODE DIAGNOSA
(SLKI) TINDAKAN (SIKI)
KEPERAWATAN

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