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DEPARTEMEN
KEPERAWATAN KRITIS
Disusun Oleh:
...............................................
I. PENGKAJIAN
A. Tanggal Masuk : ......................................................................................................................
B. Jam masuk : ......................................................................................................................
C. Tanggal Pengkajian : ......................................................................................................................
D. Jam Pengkajian : ......................................................................................................................
E. No.RM : ......................................................................................................................
F. Identitas
1. Identitas pasien
a. Nama :.............................................................................................................
b. Umur :.............................................................................................................
c. Jenis kelamin :.............................................................................................................
d. Agama :.............................................................................................................
e. Pendidikan :.............................................................................................................
f. Pekerjaan :.............................................................................................................
g. Alamat :.............................................................................................................
h. Status Pernikahan :.............................................................................................................
2. Penanggung Jawab Pasien
a. Nama :.............................................................................................................
b. Umur :.............................................................................................................
c. Jenis kelamin :.............................................................................................................
d. Agama :.............................................................................................................
e. Pendidikan :.............................................................................................................
f. Pekerjaan :.............................................................................................................
g. Alamat :.............................................................................................................
h. Hub. Dengan PX :.............................................................................................................
G. Pengkajian
1. Primary Survey
a. Airway
1) Posisi kepala : .....................................................................................................................
2) Secret/sputum : ...................................................................................................................
Dep. Keperawatan Kritis Prodi S1 Keperawatan STIKES ICME Jombang 2018/2019
3) Reflek batuk : .....................................................................................................................
4) Lidah jatuh :........................................................................................................................
5) Benda asing : ......................................................................................................................
6) Gigi : ...................................................................................................................................
7) Epistaksis : ..........................................................................................................................
8) Data lain : ...........................................................................................................................
b. Breathing
1) Frekuensi nafas : .................................................................................................................
2) Irama nafas : .......................................................................................................................
3) Suara nafas : .......................................................................................................................
4) Kedalaman nafas : ..............................................................................................................
5) Pola nafas : .........................................................................................................................
6) Jenis pernafasan :................................................................................................................
7) Suara tambahan : ................................................................................................................
8) Ekspansi dada : ...................................................................................................................
9) Batuk : ................................................................................................................................
10) Data lain : ...........................................................................................................................
c. Circulation
1) Tekananan darah : ..............................................................................................................
2) Bunyi jantung : ...................................................................................................................
3) Akral : .................................................................................................................................
4) Sianosis :.............................................................................................................................
5) CRT : ..................................................................................................................................
6) Suhu : ..................................................................................................................................
7) Odem : ................................................................................................................................
8) Tremor : ..............................................................................................................................
9) Data lain : ...........................................................................................................................
d. Disability
1) Kesadaran : .........................................................................................................................
2) GCS : ..................................................................................................................................
3) Respon nyeri : .....................................................................................................................
4) Respon bicara : ...................................................................................................................
5) Reflek pupil : ......................................................................................................................
6) Spasme otot: .......................................................................................................................
7) Parastesia : ..........................................................................................................................
8) ROM : .................................................................................................................................
9) Data lain .............................................................................................................................
e. Exposure
1) Cedera :...............................................................................................................................
2) Kerusakan jaringan : ...........................................................................................................
2. Secondary Survey
a. Keadaan Umum
a. Status gizi : Gemuk Normal Kurus
Berat Badan ...................................... Tinggi Badan : ...............................................
b. Sikap : Tenang Gelisah Menahan nyeri
b. Pemeriksaan Fisik
1) Breathing (B1)
a. Bentuk dada: .................................................................................................................
b. Frekuensi nafas : ...........................................................................................................
c. Kedalaman nafas : ........................................................................................................
d. Jenis pernafasan :..........................................................................................................
e. Pola nafas : ...................................................................................................................
f. Retraksi otot bantu : .....................................................................................................
g. Irama nafas : .................................................................................................................
h. Ekspansi paru : .............................................................................................................
i. Vocal fremitus : ............................................................................................................
j. Nyeri : ...........................................................................................................................
k. Batas paru : ...................................................................................................................
l. Suara nafas : .................................................................................................................
m. Suara tambahan : ..........................................................................................................
n. Pemeriksaan penunjang : ..............................................................................................
......................................................................................................................................
o. Data lain : .....................................................................................................................
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2) Blood (B2)
a. Ictus cordis : .................................................................................................................
b. Nyeri : ...........................................................................................................................
c. Batas jantung : ..............................................................................................................
d. Bunyi jantung : .............................................................................................................
e. Suara tambahan : ..........................................................................................................
f. Pemeriksaan penunjang : ..............................................................................................
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g. Data lain : .....................................................................................................................
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c. Terapi Medik
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