FORMAT PENGKAJIAN KRITIS.doc

PROGRAM STUDI PENDIDIKAN NERS FAKULTAS FAKULTAS KEPERAW KE PERAWAT ATAN AN UNIVERSITAS UNIVE RSITAS AIRLANGG AIRL ANGGA A PENGALAMAN BELAJAR PRAKTIKA

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

: : : :

Jam Masuk : No. RM : Diagnosa Masuk :

 IDENTITAS   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 UTAMA

1.

+elu,an +elu,an utama:-utama:-------------------------------------------------------------------------------------------

 RIWAY  RIWAYAT PENY PENYAKIT AKIT SEKARANG 

1. Riwa*at Riwa*at Pen*ak Pen*akitSek itSekara arang: ng: ------------------------------...................................... ----------------------------------------.......................................................................................................................................................... ----------------------------------------.......................................................................................................................................................... ----------------------------------------..........................................................................................................................................................  RIWAY  RIWAYAT PENY PENYAKIT AKIT 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: ................................................................................................................................................................ ................................................................................................................................................................. ................................................................................................................................................................

 RIWAY  RIWAYAT KESEHAT KESEHATAN AN 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

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