PENGKAJIAN KEPERAWATAN

KASUS NON TRAUMA _______________________

A. DATA UMUM
Nama
Umur
Alamat
No. Registrasi
Diagnosa Medis
Tanggal MRS
Tanggal pengkajian

: ____________________________________________________
: ________ Tahun/ Bulan
: ____________________________________________________
____________________________________________________
: _______________________
: ____________________________________________________
: _______________________
: _______________________

B. DATA KHUSUS
1. Subyektif
i. Keluhan utama
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__________________________________________________________________
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ii. PQRST
Provokes/Palliates : ____________________________________________
____________________________________________
Quality
: ____________________________________________
____________________________________________
Region/Radiation : ____________________________________________
____________________________________________
____________________________________________
Severity
: ____________________________________________
____________________________________________
Timing
: ____________________________________________
____________________________________________
2. Obyektif
i. Airway
Snoring ( )

Stridor ( )

ii. Breathing
Gerakan dada simetris
Gerakan diafragma
Rhonci

( ) ya
( ) Normal

Gurling ( )

Wheezing

( ) tidak
RR :
( ) Distensi abdomen

x/menit
( ) Acites

iii. Circulation
Hb :
mg/dl, Akral tangan dan kaki : ( ) Hangat ( ) Dingin
TD :
/
mmHg. SaO2 :
%. HR :
x/menit

iv. Disabiity
GCS : E:
V:
M:
PERL : Pupil ( ) Ishocoor ( ) Unisocoor, reaksi cahaya

v. Exposure & Environtment

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__________________________________________________________________
__________________________________________________________________
vi. Full vital sign, five intervention
TD
: _______ mmHg
S
: _______________ oC
RR
: _______ x/menit
SaO2
: ________________%
HR
: _______ x/menit
IVFD
: _________________
Kateter Urine : Produksi Urine
cc/jam
Warna urine ( ) jernih ( ) keruh. Darah ( ) ada ( ) tidak ada
NGT
: _____________________________________________________
Hasil pemeriksaan laboratorium tanggal : _________________________________
Darah Lengkap
Leukosit : ______________ /ul (Normal 35000 10.000)
Hb
: _____________ gr/dl
(Normal 11-16.5)
PVC
: _______________ %
(Normal 35-50)
Trombosit: ______________ /ul(Normal 150.000-390.000)
Kimia Darah
Gual Darah Puasa _______ mg/dl
2 jam PP : ____________ mg/dl
Gual darah Sesaat _______ mg/dl (Normal <120 mg/dl)
Ureum : ____________ mg/dl
(Norml 10-50)
Creatinin : ____________ mg/dl
(Normal 0,7 1,5)
Analisa Elektrolit
Natrium : ___________ mmol/l
(Normal 136-145)
Kalium : ___________ mmol/l
(Normal 3,5-5)
Clorida : ___________ mmol/l
(Normal 98-106)
BGA Test
Suhu
: ______________ oC
pH
: ________________
(Normal 7,35 7,45)
PCO2
: ___________ mmHg
(Normal 35-45)
PO2
: ___________ mmHg
(Normal 80-100)
HCO3
: ________________
(Normal 21 28)
SaO2
: _______________ %
(Normal 85-95)
Base Excess ________________
(Normal -3-+3)
vii. Give comfort
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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viii. History
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__________________________________________________________________
__________________________________________________________________
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Head to toe
1. Kepala
2. Mata
3. Hidung

4. Telinga
5. Mulut & Faring

6. Leher

: Bentuk : ( ) Normal ( ) Tidak normal; Grimace ( )

Laserasi / jejas ( ); kepala ( ) bersih ( ) kotor
: Palpebra oedema ( / ); skera ikterik ( / ); reflek cahaya ( / )
Conjunctiva anemis ( / ); pupil : ( ) Ishokor ( )Anishokor
: Bentuk : ( ) Normal ( ) Tidak normal; Laserasi/jejas ( );
Epistaksis ( ); Rhinorea ( ); nyeri tekan ( ); pernafasan
cuping hidung ( ); terpasang nasal kanul ( )/
rebreathing ( )/ nonrebreathing mask ( )/ tdk, O2 :
L
: Bentuk : ( ) Normal ( ) Tidak normal; Laserasi/jejas ( );
keadaan bersih ( )/ kotor ( ), otorhea ( )
: keadaan mulut : bersih ( )/ kotor ( ), Bibir : Lembab ( )/
Kering ( ), Lidah : kotor ( )/ bersih ( ), Terpasang
orofaringeal tube : ya ( ) tidak ( ), ETT : ya ( ) tidak ( ),
produksi sekret ( )
: Trachea : Pembesaran ya ( ) / tidak ( ), Pergeseran ada ( )/
tidak ( ); distensi Vena jugularis : ya ( ) / tidak ( )
:

7. Thorax
Inspeksi
Bentuk : simetris ( ) / tidak ( ) normal ( ) / tidak ( ), Laserasi dan jejas ( ),
retraksi interostae ( ), retraksi suprasternal ( )
Palpasi
Krepitasi ( ), nyeri tekan ( ), emphisema subcutis ( ), pergerakan dinding dada
simetris ya ( )/ tidak ( )
8. Paru
Perkusi Paru
: _______________________________________
Auskultasi
:
Ronchi
Wheezing
Rales

9. Jantung
Ictus cordis pada :__________, suara jantung I dan II tunggal ( )/ split ( ),
murmur ( ), irama teratur ( ) / tidak ( ), perkusi : pembesaran jantung ya ( ) /
tidak ( ), HR :___________x/menit
10. Abdomen
Bentuk abdomen : flat ( )/ cekung ( )/ distended ( ), bayangan pembuluh darah
pada perut ( ) ada / ( ) tidak, peristaltik usus ( ) ada / ( ) tidak, frekuensi :___/mnt,
benjolan pada abdomen ( ) ada / ( ) tidak, ( ) nyeri tekan, Turgor kulit ( ) baik /
( ) menurun

11. Ekstrimitas
( ) infus, ( ) restrain, tulang : ( ) simetris / ( ) tidak, ROM : ( ) terbatas /
( ) bebas, ( ) edema, kekuatan otot

12. Pelvis dan genetalia

Urogenetalia
: cateter ( ) ya / ( ) tidak, produksi urine ____cc/jam,
warna ( ) jernih / ( ) keruh, darah ( ) ada / ( ) tidak
ix. Inspeksi back/posterior surface
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ANALISA DATA

NO.

TGL

DATA

ETIOLOGI

PRIORITAS DIAGNOSA KEPERAWATAN

1.
2.
3.

MASALAH

RENCANA KEPERAWATAN

NO. Dx No

Tujuan & Kriteria

Hasil

Intervensi

Rasional

IMPLEMENTASI

Tgl/Jam

Dx
No

Implementasi

Respon Pasien

Paraf
Perawat

EVALUASI

Tgl/
Jam

Dx No

Evaluasi

Paraf
Perawat