Professional Documents
Culture Documents
PENGKAJIAN
Tanggal masuk
Tanggal pengkajian
A. Identitas Pasien
Nama
Umur
Alamat
No Register
Ruang
Cara Pengkajian
Diagnosa Medis
Penanggung jawab :
B. Riwayat Kesehatan
1. Keluhan utama
II.
PENGKAJIAN PRIMER
Airway
Breathing
Circulation
Disability
Explosure
III.
PENGKAJIAN SEKUNDER
A. Pemeriksaan fisik
1. Keadaan Umum
2. Tanda-tanda vital
Tanggal
3. Kepala
Bentuk
mata
hidung
telinga
mulut
leher
4. Dada
Inspeksi
Palpasi
Perkusi
Auskultasi
5. Abdomen
Inspeksi
Auskultasi
Perkusi
TD
Nadi
RR
Suhu
Palpasi
6. Ekstremitas
Ekstremitas Atas
Kanan
Tanggal/
jam
Kesemutan
Edema
Kiri
Nyeri
Kesemutan
Edema
Nyeri
Gerak
Kekuatan Otot :
Ekstremitas Bawah
Kanan
Tanggal/
jam
Kesemutan
Edema
Kiri
Nyeri
Kesemutan
Edema
Nyeri
Gerak
Kekuatan Otot :
7. Sistem Integumen
Tanggal/jam
Warna kulit
Turgor
8. Genetalia
9. Sistem Persyarafam
a) Fungsi serebral/Status Mental
Tanggal
Status mental
Tingkat kesadaran
GCS
Gaya bicara
Fungsi Intelektual
Mukosa
bibir
Capillary
refill
Kelainan
Orientasi waktu
Orientasi tempat
Orientasi orang
Daya pikir
Spontan, alamiah, masuk
akal
Kesulitan berpikir
Halusinasi
Status emosional
Alamiah dan datar
Pemarah
Cemas
Apatis
10. Eliminasi
Intake
Parenteral :
Output
Balance Cairan
Urine :
IWL :
Feses :
Muntah :
Drainase :
Total :
Minum :
Makan :
Total :
Satuan
Nilai
Hb
Ht
Eritrosit
Leukosit
Trombosit
Creatinin
Albumin
Gula Sewaktu
Ureum
Na
K
Cl
13 - 16
40 - 54
45 - 65
4 - 11
150 - 400
0.6 - 1.3
3.4 - 5
80 - 120
15 - 39
136 - 145
3.5 - 5.1
98 - 107
%
%
jt/ mmk
ribu/ mmk
ribu/mmk
mg/ dL
mg/ dL
mg/ dL
mg/ dL
mmol/ L
mmol/ L
mmol/ L
Nilai
Nilai
Cholesterol
Trigliserid
Waktu
50 - 200
30 - 150
10 - 15
mg/ dL
mg/ dL
dtk
protrombin
PPT kontrol
Waktu
12.8
23.4 -
dtk
tromboplastin
pH
36.8
7,35
pCO2
pO2
HCO3
AADO2
Laktat
Base Excess
3,45
35 - 45
83 - 103
18 - 23
<100
0,4 - 2
mmHg
mmHg
Mmol/L
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13.Therapy
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ANALISA DATA
Nama :
No CM :
Usia
Dianosa Medis :
TANGGAL
DATA FOKUS
ETIOLOGI
MASALAH
TTD
No CM :
Usia
Diagnosa Medis :
No
:
DIAGNOSA
Dx. KEPERAWATAN
INTERVENSI
TTD
IMPLEMENTASI KEPERAWATAN
TGL/JAM
NO.
DX.
IMPLEMENTASI
RESPON
TTD
EVALUASI
Nama :
No CM :
Usia
Diagnosa Medis :
TGL/JAM
NO
DX
EVALUASI ( SOAP )
TTD