FALSE
TRIASE / NON
RESUSITASI EMERGENCY URGENT EMERGEN
KATEGORI URGENT
CY
JALAN NAPAS □ Sumbatan □ Stridor/disstres □ Bebas □ Bebas □ Bebas
□ Henti □ Napas □ Napas □ Napas □ Napas
Napas >32x/menit 24-32 x/menit Normal 16- Normal 16-
PERNAPASAN
□ Napas □ Wheezing □ Wheezin 20 x//menit 20 x//menit
<10x/menit g
□ Sianosis
□ Henti □ Nad □ Nadi 100-150 □ □
Jantung i tidak x/menit Nadi Nadi
□ Nad teraba/lemah □ TD Normal Normal
i tidak □ Brad Sistole □
teraba/lemah ikardia >160 mmHg Perdarahan Luka
□ Pucat (<50x/mnt) □ TD Ringan Ringan
□ Akral □ Tak Diastole □ C
Dingin ikardia >100 mmHg edera
SIRKULASI □ GDA < (>150x/mnt) □ Perd Kepala
80 □ Pucat arahan ringan
mg/dl □ Akral Dingin sedang □ M
□ GDA >200 □ CRT >2 setik □ Muntah untah /
mg/dl □ TD □ dehidrasi diare tanpa
Sistole <100 □ Keja dehidrasi
□ Kejang
mmHg ng tapi sadar □
□ TD □ Nyeri Nyeri
Diastole <60 ringan
Sedang
mmHg
□ Nyeri akut (>8)
□ Perdarahan akut
□ multiple Fraktur
□ Suhu >39 C
DISABILITY □ GCS <9 □ GCS 9-12 □ GCS >12 □ GCS 15 □ GCS 15
AREA P1 P2 P3
RESPON TIME 1 MENIT 10 MENIT 60 MENIT
Pengkajian Perawat, jam: Riwayat Penyakit Dahulu:
Keluhan utama (SAMPLE): □ TB
Kanker Infark Miokard
□ PPOK Hepatitis
Peny.Jantung
□ DM Hipertensi
1
Stroke
□ Kejang Asma
Lain2:
Riwayat Pemakaian Alkohol:
□ YA TIDAK Jml/hri:
Riwayat Merokok:
□ YA TIDAK Jml/hri:
Riwayat Alergi:
2
□ YA TIDAK Jenis Alergi:
TD: mmHg Nadi: x/menit SUHU: C TB: cm / BB:
Kg
GDA: mg/dl SaO2: % Skala Nyeri (0-10): Status Gizi:
Skala Nyeri Untuk Umur > 9 Tahun: Skala Nyeri Untuk Umur < 9 Tahun: NILAI SKALA
NYERI:
□0 (Tidak
Nyeri)
□ 1-3
(Ringan)
□ 4-6
(Sedang)
□ 7-10
(Berat)
Diagram kode diagram
A : Abrasi
B: Bruise
Bu : Burn
E : eritema
L : laserasi
P : Ptekie
Pu : Pressure
ulcer R : Rash
S : Scar
ST: stoma
U : Ulcer
O : other (tato,
amputasi, perubahan
warna)
Ket:
Pemeriksaan fisik head to toe) (DCAPBTLS): (D=Deformitas, C=Contution, A=Abration, P=Penetration, B=Burns,
T=Tenderness, L=Laceration, S=Swelling)
A. Kepala:
B. Leher:
C. Bahu :
3
D. Dada:
E. Perut :
F. Genitalia:
G. Punggung:
H. Panggul:
I. Tangan:
J. Kaki:
4
Keterangan:
Tingkatan Risiko Nilai MFS Tindakan
Tidak berisiko 0 - 24 Perawatan dasar
Risiko rendah 25 - 50 Pelaksanaan intervensi pencegahan jatuh standar
Risiko tinggi ≥ 51 Pelaksanaan intervensi pencegahan jatuh risiko tinggi
Pemeriksaan diagnostic jam : RENCANA PROSEDUR
□ tidak ada USG □ orofaringeal airway terapi
□ darah lengkap X Ray nasogastrik
□ BUN MRI □ nasofaringeal airway kateter urin
□ enzim jantung CT scan □ intubasi ETT kateter vena sentral
□ glukosa lain-lain (CVP)
□ tes fungsi hati urinalisis □ terapi oksigen perawatn
□ gas darah arteri tes Ob/Gyn
kehamilan □ terapi nebulizer perawatan
□ alcohol dalam darah oksmetri orthopedic
nadi □ CPR terapi trombolitik
□ HIV serologi EKG □ IV fluid perawatan luka
□ DC shock lain-lain :
DIAGNOSIS MEDIS:
DIAGNOSIS
KEPERAWATAN:
5
PERENCANAAN DAN IMPLEMENTASI
JAM TINDAKAN
6
EVALUASI
Suhu:
Bila dirujuk/alih rawat, Tanggal: Jam:
SpO2:
GCS:
Malang,
Ttd Perawat
(……………………………)
7
FORMAT ASUHAN KEPERAWATAN KRITIS
FORMAT PENGKAJIAN KEPERAWATAN
Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :
Hari rawat ke :
IDENTITAS KLIEN
1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Status Kawin :
5. Suku/ Bangsa :
6. Agama :
7. Pendidikan :
8. Pekerjaan :
9. Alamat :
10. Sumber Biaya :
KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
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8
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……………………
5. Lain-lain:
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
:………………….....................................................................................................................................
- Genogram :
Jenis................................................ Flow..............lpm
9
j. Penggunaan WSD:
- Jenis
: .....................................................................................................................................................
............
- Jumlah cairan
: ..................................................................................................................................................
- Undulasi
:...................................................................................................................................................
- Tekanan
: ..................................................................................................................................................
k. Tracheostomy: ya tidak
......................................................................................................................................................................
......................................................................................................................................................................
l. Lain-lain:
......................................................................................................................................................................
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10
4. Sistem Persyarafan (B3)
a. GCS : .................................................. Masalah Keperawatan :
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky brudzinsky kernig
Lain-lain
d. Keluhan pusing ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
11
f. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
g. Kandung kemih : Membesar ya tidak
h. Nyeri tekan ya tidak
i. Intake cairan oral : ……… cc/hari parenteral................cc/hari
j. Balance cairan:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
k. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................
12
Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lens
a
TIO
8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphan
i Rinne
Weber
Swabach
13
b. Tes Audiometri
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
14
j. Kompartemen syndrome ya tidak
k. Kulit: ikterik sianosis kemerahan hiperpigmentasi
l. Turgor baik kurang jelek
m. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : .................................................
q. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
15
10. Sistem Integumen
a. Penilaian resiko decubitus
Nilai
Kriteria Penilaian
Aspek Yang 1 2 3 4
Dinilai
Persepsi Terbatas Sangat Keterbatasan Tidak Ada
Sensori Sepenuhnya Terbatas Ringan Gangguan
Kelembaban Terus Sangat Kadang2 Basah Jarang
Menerus Lembab Basah
Basah
Aktifitas Bedfast Chairfast Kadang2 Jalan Lebih Sering
jalan
Mobilisasi Immobile Sangat Keterbatasan Tidak Ada
Sepenuhnya Terbatas Ringan Keterbatasan
Nutrisi Sangat Kemungkinan Adekuat Sangat Baik
Buruk Tidak
Adekuat
Gesekan & Bermasalah Tidak
Potensial
Pergeseran Menimbulkan
Bermasalah
Masalah
NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan Total Nilai
bahwa pasien beresiko mengalami dekubisus (pressure ulcers)
(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less =
high
risk)
g. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
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TERAPI MEDIS
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PERENCANAAN PULANG
- Tujuan Pulang:
- Transportasi Pulang:
- Dukungan Keluarga:
- Pengobatan:
Malang, 2019
(……………………………)
19
ANALISA DATA
Nama Pasien :
Umur :
No. Register :
Hari/
Tgl/ DATA ETIOLOGI MASALAH
Jam
20
DIAGNOSA KEPERAWATAN
Nama Pasien :
Umur :
No. Register :
1.
2.
3.
4. dst
21
PRIORITAS MASALAH KEPERAWATAN
Nama Pasien :
No. Register :
No TANGGAL TANGGAL TANDA
DX MUNCUL DIAGNOSA KEPERAWATAN TERATASI TANGAN
22
RENCANA ASUHAN KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ Tgl/
No. DIAGNOSA KEPERAWATAN LUARAN KEPERAWATAN INTERVENSI
Jam
23
IMPLEMENTASI
Nama Pasien :
No. Register :
HARI/ TGL/
NO. DX JAM IMPLEMENTASI PARAF JAM RESPON PARAF
SHIFT
24
EVALUASI KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ Tgl/
Diagnosa Kep Jam Evaluasi Paraf
Shift
25
26