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Nursing Assessment Mix

Nursing Assessment Mix

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Published by Yulius Tiranda

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Published by: Yulius Tiranda on Jun 25, 2012
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01/13/2013

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NURSING ASSESSMENT
I.
 
Data Demografi
Nama pasien: _____________________________________________JK: _______________ Umur: _________ Agama: ____________ Suku: _______________________Alamat: _________________________________________________________________________No MR: _____________________Tgl MRS: ________________ Tgl Pengkajian: ________________Sumber Informasi:____________________________________
II.
 
Riwayat Kesehatan
a.
 
Riwayat Kesehatan Sekarang1.
 
Keluhan Utama:_________________________________________________________2.
 
....b.
 
Riwayat Kesehatan Masa Lalu: ___________________________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________c.
 
Riwayat Kesehatan Keluarga: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
III.
 
Alergi:
a.
 
Obat:______________________________________b.
 
Makanan:___________________________________
IV.
 
Pengkajian Keperawatana.
 
Aktivitas dan IstirahatObjektif Subjektif 
Status Kesadaran:__________Mobilitas: ___Ambulasi ___Non AmbulasiTonus/kekuatan otot:
 
Tonus/massa otot:_______________
 
Postur:____________
 
Tremor:___________
 
ROM:_____________
 
Kekuatan:__________
 
Deformitas:_________Penggunaan alat bantu:________________Homan Sign:
 
Kanan:___(+) ___(-)
 
Kiri :___(+) ___(-)
 
Aktivitas sehari-hari:__________________Hobby:______________________Keterbatasan karena kondisi:_____________Tidur: Jam_____ Tidur siang:_____________Alat bantu:______________________Insomnia:_____ Faktor penyebab:_________Puas akan tidurnya_____________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________
Catatan:
Kaji mobilisasi, cara berjalan, fungsi sendi, reflek otot. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Diagnosa Keperawatan:
Intoleransi aktivitas___ Gangguan Pola Tidur____ Fatique______Kerusakan mobilitas fisik___ Lainnya:______________
 
b.
 
SirkulasiObjektif Subjektif 
Suhu:_______________°CTekanan darah:_____________mmHgNadi:
 
Karotid:__________________________
 
Jugular:__________________________
 
Radial:___________________________
 
Post-tibial:_______________________
 
Femoral:_________________________
 
Dorsalis pedis:____________________Re: Regular Ire: Iregular K: Kuat L: LemahTa: Tidak ada H: Halus Ka: Kanan Ki: KiriSuara jantung: Ritme_______ Rata2:_______Friciton Rub________ Murmur:_____JVP:____(+) ____(-)Capilarry refill:___________Edema:_____Pitting ____Non PittingLokasi:_________________________Varikositis:_____Ya _____TidakWarna kuku:_____Pink ____Biru ____Pucat
Riwayat:
 ___Hipertensi ___Demam Rematik ___Phlebitis ___Masalah jantung ___Edema ankle dan lutut ___Penyembuhan luka yang lama _____________________________________ _____________________________________ _____________________________________Klaudikasio:____________________________Disrefleksia:____________________________Perdarahan:____________________________Palpitasi:______________________________Syncope:______________________________Ekstremitas: Mati rasa:_____________Tingling:______________Hemoptisis:____________________________Jumlah urine menurun:__________________Latihan:
 
Tipe:______________________________
 
Frekuensi:_________________________
 
Durasi:___________________________
Catatan:
Kaji suara jantung, ritme, nadi, tekanan darah, retensi cairan dan kenyamanan ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Diagnosa Keperawatan:
Penurunan kardiak output_______ Tidak efektifnya perfusi jaringan_______________Kelebihan volume cairan______ Lainnya:______________
c.
 
EliminasiObjektif Subjektif 
Abdomen. Lunak____ Lembut_____Distensi________ Tidak________Bowel Sound:___________________Tipe:____________________Warna urine:_____________________Edema:______Ya __________TidakLokasi:__________________________Balance cairan:Intake_____________ Output:___________Hemorhoid:__________________________Pola BAB:_________________________Penggunaan laksatif:_________________Karakter feses:_________Diare:________Konstipasi:__________Pola BAK:___________________________Frekuensi:_________Incontinensia:_______ Retensi:________Urgency:__________Karakter urine:_____________Diet:_____________________________Aktivitas fisik:______________________Penggunaan diuretik:______________
 
Catatan:
Kaji frekuensi urine, warna, bau, perdarahan, keluaran ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Diagnosa Keperawatan
Diare____ Retensi urine___ Kelebihan Volume cairan ___Kekurangan volume cairanNausea____ Konstipasi______ Lainnya:______________
 d.
 
Makanan dan cairanObjektif Subjektif 
BB:_____ TB:________ BMI:_______Turgor Kulit:_________Membran mukosa: ____Lembab ____KeringIV line:__________________Tanggal insersi:_______________Tipe tubuh:__________________________Kehilangan nafsu makan:_______________Diet:________________Suplement/vitamin:____________________Makanan yang disukai:__________________Pantangan:___________________________Kehilangan nafsu makan:______________Mual/muntah:_____________________Mulas:_________________________Kesulitan menelan:__________________BB:____________ Perubahan:__________Penggunaan diuretik:__________________
Catatan:
Kaji kebiasaan eliminasi, menelan dan kenyamanan ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
Diagnosa Keperawatan:
Kerusakan menelan___ Ketidakseimbangan nutrisi;kurang dari kebutuhan___Ketidak seimbangan nutrisi; lebih dari kebutuhan________Lainnya:______________
e.
 
NeurosensoriObjektif Subjektif 
Status Kesadaran:___________________GCS:________________Orientasi: Waktu______ Orang_______Tempat_________Cushing Triad (Perubahan Respirasi, PeningkatanBP, Penurunan Kesadaran) _______(+) _________(-)Pupil: _______Simetris __________TidakUkuran:____PERRLA _______AnisokorReaksi thd cahaya: ______(+) ______(-)Fungsi Sensori: ______(+) ______(-)Lokasi:__________________________Fungsi Motorik: ______(+) ______(-)Lokasi:__________________________Reflek Fisiologis:_____________________Reflek Patologis:_____________________Pusing:_________________Sakit kepala: Lokasi__________________Frekuensi:___________________Tingling/mati rasa/kelemahan:Lokasi:_______________________Stroke/injuri otak:_________________Kejang: Tipe:_____________________Frekuensi:______________Mata: Rabun:_________ Glaukoma:_______Katarak:____________Telinga: Penurunan:____________Epistaksis:______________________

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