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PROGRAM STUDI PENDIDIKAN NERSFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGAPENGALAMAN BELAJAR PRAKTIKA
FORMAT PENGKAJIAN KEPERAWATAN KRITISTanggal MRS:
Jam Masuk :
Tanggal Pengkajian:
No. RM
:
Jam Pengkajian:
Diagnosa Masuk:
Hari rawat ke:IDENTITAS
1. Nama Pasien:
2. Umur:
3. Suku/ Bangsa:
4. Agama:
5. Pendidikan:
6. Pekerjaan:
7. Alamat:8. Sumber Biaya :KELUHAN UTAMA1. Keluhan utama:
RIWAYAT PENYAKIT SEKARANG
1. Riwayat PenyakitSekarang:....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT DAHULU
1. Pernah dirawat
: ya tidak kapan : diagnosa :
2. Riwayat penyakit kronik dan menular yatidak jenis
Riwayat kontrol : .............................
Riwayat penggunaan obat :..............
3. Riwayat alergi:
Obatya tidakjenis
Makanan yatidakjenis
Lain-lain yatidakjenis
4. Riwayat operasi:
ya tidak
Kapan :
Jenis operasi :
5. Lain-lain:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT KESEHATAN KELUARGA
Ya
tidak
Jenis:........................................................................ Genogram:
PERILAKU YANG MEMPENGARUHI KESEHATAN
Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkoholya tidakketerangan.........................................................
Merokokyatidak
keterangan.........................................................
Obatyatidak
keterangan..............................................................
Olahraga yatidak
keterangan..........................................................OBSERVASI DAN PEMERIKSAAN FISIK
1. Tanda tanda vital
S :
N :
T :
RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
2. Sistem Pernafasan (B1)a. RR:................................b. Keluhan:
sesak
nyeri waktu nafas
orthopnea
Batuk
produktiftidak produktif
Sekret:..
Konsistensi :......................
Warna:..........
Bau :..................................
c. Penggunaan otot bantu nafas:...............................................................................................................................................................................................................................................................................................................d. Irama nafas
teratur
tidak teratur
e. Pleural Friction rub:.....................................................................................................................f. Pola nafas
Dispnoe
KusmaulCheyne Stokes Biotg. Suara nafas
Cracles
Ronki
Wheezingh. Alat bantu napas
ya tidak
Jenis................................................Flow..............lpmVentitalor
Mode:
FiO2:
PEEP:
SaO2:
Vol. Tidal:
I:E Ratio:
Lain-lain :
i. Penggunaan WSD: Jenis: ...................................................................................................................... Jumlah cairan: ...................................................................................................................... Undulasi:...................................................................................................................... Tekanan: ......................................................................................................................j. Tracheostomy: yatidak
...............................................................................................................................................................................................................................................................................................................k. Lain-lain:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Sistem Kardio vaskuler (B2)a. Keluhan nyeri dada:
ya
tidak
P:...................................................................Q:...................................................................R:...................................................................S:...................................................................T:...................................................................b. Irama jantung:
reguler
ireguler
c. Suara jantung:
normal (S1/S2 tunggal)
murmur
gallop
lain-lain.....
d. Ictus Cordis: ..................................................................................................................................e. CRT :.............detik
f. Akral:hangatkeringmerahbasahpucat
panasdinging. Sikulasi perifer: normal menurunh. JVP:.................................i. CVP:.................................
j. CTR:.................................k. ECG & Interpretasinya:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................l. Lain-lain :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4. Sistem Persyarafan (B3)a. GCS : ..................................................b. Refleks fisiologis
patella
triceps
biceps
c. Refleks patologis
babinskybrudzinskykernigLain-laind. Keluhan pusing
ya
tidak
P:...................................................................
Q:...................................................................
R:...................................................................
S:...................................................................
T:...................................................................e. Pemeriksaan saraf kranial:N1:normaltidak
Ket.: ..............................................................
N2:normaltidak
Ket.: ..............................................................
N3:normaltidak
Ket.: ..............................................................
N4:normaltidak
Ket.: ..............................................................
N5:normaltidak
Ket.: ..............................................................
N6:normaltidak
Ket.: ..............................................................
N7:normaltidak
Ket.: ..............................................................
N8:normaltidak
Ket.: ..............................................................
N9:normaltidak
Ket.: ..............................................................
N10:normaltidak
Ket.: ..............................................................
N11:normaltidak
Ket.: ..............................................................
N12:normaltidak
Ket.: ..............................................................
f. Hoffman/Tromer test:
g. Pupil
anisokor
isokor
Diameter: /......
h. Sclera anikterusikterus
i. Konjunctiva ananemis anemisj. Isitrahat/Tidur :................. Jam/Hari
Gangguan tidur : ........................
k. IVD:................................................l. EVD:................................................m. ICP:................................................n. Lain-lain:............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... o. Tanda-Tanda PTIK: p. Gangguan pendengaran: Ada Tidak , Jelaskan:
q. Gangguan penglihatan : Ada Tidak, Jelaskan:
r. Gangguan Penciuman ; Ada Tidak, Jelaskan
5. Sistem perkemihan (B4)a. Kebersihangenetalia:Bersih Kotor
b. Sekret: Ada Tidakc. Ulkus: Ada Tidakd. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada TidakBila ada, jelaskan:
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
f. Kemampuan berkemih:SpontanAlat bantu, sebutkan: .......................................................................
Jenis:............................................
Ukuran:............................................
Hari ke:............................................g. Produksi urine : ..ml/jam
Warna:............
Bau:........
h. Kandung kemih : Membesar
ya tidak
i. Nyeri tekan ya tidak
j. Intake cairanoral : cc/hari parenteral : cc/hari
k. Balance cairan:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................o. Lain-lain:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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 menelankesulitan menelan
pembesaran tonsilnyeri tekan
g. Abdomen: tegang kembungascites
h. Nyeri tekan: ya tidak
i. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain :ada
tidak
Jumlah :...................
Warna :................... Kondisi area sekitar insersi :...................
j. Peristaltik:.............. x/menit
k. BAB: ......................x/hari
Terakhir tanggal : ..............
l. Konsistensi: keraslunakcairlendir/darah
m. Diet:padatlunakcair
n. Diet Khusus:
............................................................................................................................................................................................................................................................
o. Nafsu makan:baikmenurun
Frekuensi:.......x/hari
p. Porsi makan: habistidak
Keterangan:.......................
q. Lain-lain:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................7. Sistem muskuloskeletal (B6)a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot:
c. Kelainan ekstremitas:yatidak
d. Kelainan tulang belakang:ya tidak
Frankel: ................................................................................e. Fraktur: yatidak
Jenis:...................
f. Traksi:yatidak
Jenis:...................
Beban:...................
Lama pemasangan:...................
g. Penggunaan spalk/gips:yatidak
h. Keluhan nyeri:ya tidak
P:...................................................................
Q:...................................................................
R:...................................................................
S:...................................................................
T:...................................................................i. Sirkulasi perifer: ..............................................j. Kompartemen syndromeya tidak
k. Kulit:ikteriksianosis kemerahanhiperpigmentasi
l. Turgor baik kurang jelek
m. Luka operasi: adatidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain :adatidak
Jumlah :...................
Warna :...................
Kondisi area sekitar insersi :...................
n. ROM:................................................o. Lain-lain:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
p. Pitting edema: +/- grade:................
q. Ekskoriasis:ya tidak
r. Urtikaria:ya tidak
s. Lain-lain:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Sistem Endokrin
a. Pembesaran tyroid:yatidak
b. Pembesaran kelenjar getah bening:yatidak
c. Hipoglikemia:yatidak
d. Hiperglikemia:yatidake. Lain-lain:..................Jelaskan:..................................................
PENGKAJIAN PSIKOSOSIAL
f. Persepsi klien terhadap penyakitnya:.............................................................................................................................................................................................................................................................................................................................................................................................
g. Ekspresi klien terhadap penyakitnya
Murung/diam gelisah tegang marah/menangis
h. Reaksi saat interaksi kooperatiftidak kooperatif curiga
i. Gangguan konsep diri:
.............................................................................................................................................................................................................................................................................................................................................................................................j. Lain-lain:...............................................................................................................................
...............................................................................................................................
...............................................................................................................................PERSONAL HYGIENE & KEBIASAAN
Jelaskan
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
Sebelum sakit sering kadang- kadangtidak pernah
Selama sakit sering kadang- kadangtidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:...............................................................................................................................
...............................................................................................................................
...............................................................................................................................PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)
TERAPIDATA TAMBAHAN LAIN :Surabaya, ..20...()
PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
ANALISIS DATA
TANGGALDATAETIOLOGIMASALAH
PROGRAM STUDI ILMU KEPERAWATANFAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN
TANGGAL: .................................1.
2.
3.
4.
5.6. RENCANA INTERVENSIHARI/
TANGGALWAKTUDIAGNOSA KEPERAWATAN
(Tujuan, Kriteria Hasil)INTERVENSIRASIONAL
IMPLEMENTASI DAN EVALUASI KEPERAWATANHari/Tgl/ShiftNo. DKJamImplementasiParafJamEvaluasi (SOAP)Paraf
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