Format Pengkajian Kritis

PROGRAM STUDI PENDIDIKAN NERS FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA PENGALAMAN BELAJAR PRAKTIKA

FORMAT PENGKAJIAN KEPERAWATAN KRITIS Tanggal MRS Tanggal Pengkajian Jam Pengkajian Hari rawat ke

: : : :

Jam Masuk : No. RM : Diagnosa Masuk :

 IDENTITAS 

1. 2. 3. ". $. &. '. (.

Nama Pasien Umur: 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 itSekara arang: 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an : ------- Jeni Jeniss oe oerrasi : ---------

*a

ti%ak  

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

 RIWAYAT KESEHATAN KESEHATAN KELUARGA

 

a Jeni Jeniss

ti%ak   :--:--------... -..... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ....

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.

2.

Tanda tanda vital S: N: T: +esa%aran 4omos Mentis

RR : #atis

Somnolen

Soor

+oma

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<

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

e. Pemeriksaan sara5 kranial:  N1 : normal  N2 : normal  N3 : normal  N" : normal  N$ : normal  N& : normal  N' : normal  N( : normal  NA : normal

ti%ak ti%ak ti%ak ti%ak ti%ak ti%ak ti%ak ti%ak ti%ak

Masala, +eerawatan : )i7es kernig

+et.: --.............................................................. +et.: --.............................................................. +et.: --.............................................................. +et.: --.............................................................. +et.: --.............................................................. +et.: --.............................................................. +et.: --.............................................................. +et.: --.............................................................. +et.: --..............................................................

3

 N1B :  N11 :  N12 :

normal normal normal

ti%ak ti%ak ti%ak

+et.: --.............................................................. +et.: --.............................................................. +et.: --..............................................................

5. g. ,. i.  j. k. l. m. n.

Ho55manTromer test : Puil anisokor isokor Diameter: --...... S7lera anikterus ikterus +onjun7tiCa ananemis anemis 8sitra,atTi%ur :................. JamHari angguan ti%ur : ........................ 8;D :................................................ <;D :................................................ 84P :................................................ 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! :...............  ). 8MT :............... 7. 0/0# :...............

%. Mulut: e. Mem)ran mukosa: 5. Tenggorokan: sakit menelan

!! :................................ 8nterretasi :................................

)ersi, lem)a)

kotor kering

Masala, +eerawatan :

)er)au stomatitis

kesulitan menelan

"

g. ,. i.

 j. k. l. m. n.

o.  . E.

.

 em)esaran tonsil n*eri tekan #)%omen: tegang kem)ung as7ites N*eri tekan: *a ti%ak   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 :................... Peristaltik:.............. Gmenit !#!: ......................G,ari Terak,ir tanggal : .............. +onsistensi: keras lunak 7air len%ir%ara, Diet: a%at lunak 7air   Diet +,usus: ........................................................................................................................................................ .................................................................................................... Na5su makan: )aik menurun 9rekuensi:.......G,ari Porsi makan: ,a)is ti%ak +eterangan:....................... 0ainlain: ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................

Sit!" "*)*l()!l!tal %B0& a. Pergerakan sen%i: )e)as  ). +ekuatan otot:

ter)atas

7. +elainan ekstremitas: *a ti%ak   %. +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 : ................................................

Masala, +eerawatan :

o. 0ainlain:

$

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

 . E. r. s.

3.

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

Masala, +eerawatan :

 PENGKAJIAN PSIKOSOSIAL

Masala, keerawatan :

5. Persesi klien ter,a%a en*akitn*a: ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... g.
Masala, +eerawatan :

Jelaskan

 PENGKAJIAN SPIRITUAL

a. +e)iasaan )eri)a%a, - Se)elum sakit - Selama sakit

sering sering

ka%ang ka%ang ka%ang ka%ang

ti%ak erna, ti%ak erna,

Masala, +eerawatan :

 ). !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&

'

PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA TANGGAL

DATA

ETIOLOGI

MASALA7

(

PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

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

A

REN:ANA INTERVENSI 7ARI; TANGGAL

WAKTU

DIAGNOSA KEPERAWATAN %T*<*an5 K#it!#ia 7ail&

INTERVENSI

RASIONAL

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

12