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    Format pengkajian ASKEP

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views14 pages

    Format Pengkajian

    Uploaded by

    Mughni
    Format pengkajian ASKEP

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 14

    FORMAT PENGKAJIAN

    Nama Pasien : ........................................................... No. Rekam Medis : .........................................................


    Tanggal Lahir/Umur : ................................../.............Tahun Tanggal Masuk : .........................................................
    Alamat : ........................................................... Tanggal Pengkajian : .........................................................
    Jenis Kelamin : ........................................................... Diagnosa Masuk : .........................................................
    Pekerjaan : ........................................................... ..............................................................................................

    Penanggung Jawab Keluhan Utama MRS


    Nama : ......................................................... ..............................................................................................
    Alamat : ......................................................... ..............................................................................................
    Jenis Kelamin : ......................................................... ..............................................................................................
    Pekerjaan : ......................................................... ..............................................................................................
    Hubungan Dengan Pasien : ................................................ ..............................................................................................

    Keluhan Utama Pengkajian Riwayat Penyakit Sekarang


    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................

    Riwayat Penyakit Dahulu Riwayat Kesehatan Keluarga


    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................
    .............................................................................................. ..............................................................................................

    Pola Nutrisi dan Cairan Pola Eliminasi


    Sebelum MRS : Setelah MRS : Sebelum MRS : Setelah MRS :
    Makan : ................. x/hari Makan : ................ x/hari
    ........................................... ........................................... BAK : .................. x/hari BAK : ................. x/hari
    ........................................... ........................................... ............................................. ............................................
    Minum : ................ cc/hari Minum : ............... cc/hari ............................................. ............................................
     Air Putih/Mineral  Air Putih/Mineral BAB : .................. x/hari BAB : ................. x/hari
     Alkohol  Alkohol ............................................. ............................................
     Soda  Soda ............................................. ............................................
    Pola Istirahat/Tidur Pola Aktivitas
    Sebelum MRS : Setelah MRS : Sebelum MRS : Setelah MRS :
    Tidur Jam : .......... WIB Tidur Jam : .......... WIB ............................................. .............................................
    Bangun Jam : .......... WIB Bangun Jam : .......... WIB ............................................. .............................................
     Istirahat Siang  Istirahat Siang ............................................. .............................................
    ..................... Jam/hari ..................... Jam/hari ............................................. .............................................
    Personal Hygiene Keadaan Umum
    Sebelum MRS : Setelah MRS : TD : ................. mmHg S : ................. oC
    Mandi : ........ x/hari Mandi : ........ x/hari N : ................. x/menit RR : ................. x/menit
    Sikat Gigi : ........ x/hari Sikat Gigi : ........ x/hari
    Keramas : ........ x/mgg Keramas : ........ x/mgg ..............................................................................................
    Potong Kuku : ........ x/mgg Potong Kuku : ........ x/mgg ..............................................................................................
     Mandiri  Mandiri ..............................................................................................
     Dibantu Sebagian  Dibantu Sebagian ..............................................................................................
     Dibantu Seluruhnya  Dibantu Seluruhnya

    Ponorogo, ..............................
    Tanda Tangan Perawat

    (.................................................................)

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    PEMERIKSAAN FISIK

    Kepala Keterangan
    Bentuk  Normal  Abnormal ..............................................................................................
    Mata  Normal  Abnormal ..............................................................................................
    Hidung  Normal  Abnormal ..............................................................................................
    Telinga  Normal  Abnormal ..............................................................................................
    Mulut  Normal  Abnormal ..............................................................................................
    Gigi  Normal  Abnormal ..............................................................................................
    Leher Keterangan
    Vena Jugularis  Normal  Abnormal ..............................................................................................
    Thyroid  Normal  Abnormal ..............................................................................................
    Nodus Limfe  Normal  Abnormal ..............................................................................................
    Thorax
    Paru Jantung
    I : .................................................................................. I : ..................................................................................
    ........................................................................................... ...........................................................................................
    ........................................................................................... ...........................................................................................
    ........................................................................................... ...........................................................................................
    P : .................................................................................. P : ..................................................................................
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    P : .................................................................................. P : ..................................................................................
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    A : .................................................................................. A : ..................................................................................
    ........................................................................................... ...........................................................................................
    ........................................................................................... ...........................................................................................
    ........................................................................................... ...........................................................................................
    Abdomen Ekstremitas
    I : .................................................................................. Akral Hangat Edema
    ...........................................................................................
    ...........................................................................................
    ...........................................................................................
    A : ..................................................................................
    ...........................................................................................
    ...........................................................................................
    ...........................................................................................
    P : .................................................................................. Fraktur Kekuatan Otot
    ...........................................................................................
    ...........................................................................................
    ...........................................................................................
    P : ..................................................................................
    ...........................................................................................
    ...........................................................................................
    ...........................................................................................
    Genetalia Integumen
    ........................................................................................... ...........................................................................................
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    ........................................................................................... ...........................................................................................

    Ponorogo, ..............................
    Tanda Tangan Perawat

    (.................................................................)

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    PEMERIKSAAN LABORATORIUM

    Nama : ......................................................... No. Rekam Medis : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun Tanggal : ........................................................

    Jenis Pemeriksaan Nilai Satuan Nilai Normal

    Ponorogo,..............................
    Tanda Tangan Perawat

    (.................................................................)

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    PEMERIKSAAN PENUNJANG

    Nama : ......................................................... Alamat : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................

    Tanggal Jenis Pemeriksaan Hasil


    .................................................................. ..............................................................................................
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    Ponorogo,..............................
    Tanda Tangan Perawat

    (.................................................................)

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    PENATALAKSANAAN

    Nama : ......................................................... No. Rekam Medis : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun Tanggal : ........................................................

    Injeksi ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    Terapi Per-Oral ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    Terapi Diet Khusus ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................
    ..............................................................................................

    Tindakan
     Infus..........................................................
     Oksigen.....................................................
     Kateter Urin
     Nasogastric Tube
     Orogastric Tube
     ..................................................................
     ..................................................................
     ..................................................................

    Catatan Lainnya
    ................................................................................................................................................................................................
    ............................................................................................................................................................................................. ..
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    Ponorogo,..............................
    Tanda Tangan Perawat

    (.................................................................)

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    PEMERIKSAAN NEUROLOGIS

    Nama : ......................................................... No. Rekam Medis : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun Tanggal : ........................................................

    Tingkat Kesadaran GCS :  Meningeal Sign


     CM  Delirium  Stupor E........ V........ M........  Kaku Kuduk
     Apatis  Somnolen  Coma  ......................................

    Refleks Fisiologis Refleks Patologis


     Refleks Bisep  Refleks Trisep  Refleks Babinski  ....................................
     Refleks Brakioradialis  Refleks Patela  Refleks Hoffman  ....................................
     Refleks Achilles  Refleks Chaddock  ....................................

    Nervus Cranialis
    NI Olfaktorius  Normosmia  Parosmia
     Hiposmia  Kakosmia
     Hiperosmia  Halusinasi penciuman
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    N II Optikus  Lapang pandang ....../......  Visus : ..................................
     Papila N II  Buta warna
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    N III Okulomotorius  Misosis : ....... mm/....... mm  Isokor
     Midriasis : ....... mm/....... mm  Anisorkor
     Refleks akomodasi negatif  Refleks pupil negatif
     Ptosis  Kelopak mata menutup
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    N III, Optikus  Exophtalmos  Strabismus
    N IV, Troklearis  Nistagmus  Deviasi conjugae : ....../......
    N VI Abducens  Diplopia  Ophtalmoplegic........................
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    NV Trigeminus  Kontraksi otot maseter  Refleks kornea negatif
    asimetris ....../......  Sensibilitas pipi negatif
     Sensibilitas dahi negaitif  Sensibilitas dagu negatif
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    N VII Facialis  Kedudukan alis ....../...... Sensorik khusus 2/3 lidah anterior
     Kekuatan udara pipi ....../......  Sensorik manis negatif
     Deviasi bibir ....../......  Sensorik asam negatif
     Kekuatan kelopak mata  Sensorik asin negatif
    ....../......  Sensorik pahit negatif
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    N VIII Vestibulokoklearis (Auditorius)  Test bisik : ....../......  Test Weber : ....../......
     Test Rine : ....../......  Test Swabach : ....../......
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    N IX Glosofaringeus  Deviasi uvula : ....../......  Refleks batuk negatif
    NX Vagus  Refleks muntah negatif
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    N XI Aksesorius  Kekuatan otot  Kekuatan otot trapezius
    sternocleidomastoideus ....../......
    asimetris ....../......
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................
    N XII Hipoglosus  Deviasi julur lidah ....../......  Dysartria
     Gerak lidah ke lateral ....../......  Tremor lidah
    Catatan Lain................................................................................................
    ....................................................................................................................
    ....................................................................................................................

    Catatan Lainnya
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    Ponorogo,..............................
    Tanda Tangan Perawat

    (.................................................................)

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    LEMBAR OBSERVASI

    Nama : ........................................................ Diagnosa : Tanggal : Hari Rawat Ke :


    Tanggal Lahir/Umur : ................................./.............Tahun
    Alamat : ........................................................
    Jenis Kelamin : ........................................................
    No. Rekam Medis : ........................................................

    Tanda Vital 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 Tanda Vital


    TD Suhu Resp. Nadi
    260 43 60
    240 42 55 220
    220 41 50 200
    200 40 45 180
    180 39 40 160
    160 38 35 140
    140 37 30 120
    120 36 25 100
    100 35 20 80
    80 34 15 60
    60 33 10 40
    40 32 5 20
    20 31 - 0

    Tanda Vital 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 Catatan :


    GCS
    TD
    N
    S
    R
    SpO2

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    LEMBAR OBSERVASI

    Nama : ........................................................ Diagnosa : Tanggal : Hari Rawat Ke :


    Tanggal Lahir/Umur : ................................./.............Tahun
    Alamat : ........................................................
    Jenis Kelamin : ........................................................
    No. Rekam Medis : ........................................................

    Keterangan 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 Jumlah
    Input
    Infus
    Sonde
    Output
    Urine
    Obat Injeksi

    Obat Oral

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    CATATAN PERKEMBANGAN

    Nama : ......................................................... Jenis Kelamin : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................
    Alamat : ......................................................... Diagnosis : ........................................................

    Tanggal/Jam SOAP Tanda Tangan

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    CATATAN TINDAKAN

    Nama : ......................................................... Jenis Kelamin : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................
    Alamat : ......................................................... Diagnosis : ........................................................

    Tanggal/Jam Dx TINDAKAN RESPON Tanda Tangan

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    FORMULIR TRANSFER PASIEN ANTAR RUANG

    Nama Pasien : ........................................................... No. Rekam Medis : .........................................................


    Tanggal Lahir/Umur : ................................../.............Tahun Tanggal Masuk : .........................................................
    Alamat : ........................................................... Tanggal Pengkajian : .........................................................
    Jenis Kelamin : ........................................................... Diagnosa Masuk : .........................................................
    Pekerjaan : ........................................................... ..............................................................................................
    Tanggal Transfer : ........................................................... Jam Transfer : .........................................................
    KONDISI PASIEN SEBELUM TRANSFER
    Keadaan Umum : ................................................................. Alat Bantu Yang Terpasang
    ..................................................................................................  Oksigen nasal  WSD  ....................
    Tanda Vital :  Oksigen masker  ETT  ....................
    GCS : E..... V..... M..... Resp : ................ x/mnt  IV line  Infus pump  ....................
    TD : ..................... mmHg Suhu : ................ oC  Foley Cateter  Syiringe pump  ....................
    Nadi : ..................... x/mnt  Monitor  NGT  ....................
    KESIAPAN TRANSFER
    Level Kondisi Pasien Untuk Transfer Petugas Transfer Sesuai Level Kondisi Pasien
    0  0,5  1  2  3  Dokter  Perawat/Bidan  Non Medis
    Telah menghubungi Instalasi/Unit/Ruang ............................................................................................................................
     Nama petugas yang dihubungi .............................................................................................................................................
     Informasi jawaban yang diberikan oleh petugas penerima ..................................................................................................
    Kebutuhan Peralatan Untuk Transfer Sesuai Dengan Kondisi Pasien
     Kursi roda  BVM  Defibrilator  Infus pump
     Brancar  Oksimetri  Syringe pump  Selang/masker oksigen
     Oksigen mobile  Jackson rees  Monitor  Box obat emergency
    KONDISI PASIEN SAAT SERAH TERIMA
    S : ........................................................................................... A : ......................................................................................
    ........................................................................................... ......................................................................................
    ........................................................................................... ......................................................................................
    B : ........................................................................................... ......................................................................................
    ........................................................................................... ......................................................................................
    ........................................................................................... R : ......................................................................................
    ........................................................................................... ......................................................................................
    ........................................................................................... ......................................................................................
    SERAH TERIMA
    Obat Yang Disertakan Lain-Lain Yang Disertakan
    ...................................................................................................  Hasil pemeriksaan laboratorium
    ...................................................................................................  Hasil pemeriksaan radiologi
    ...................................................................................................  Hasil pemeriksaan lainnya (USG, EKG, EEG, dll)
    ...................................................................................................  ......................................................................................
    ...................................................................................................  ......................................................................................
    ...................................................................................................  ......................................................................................
    ...................................................................................................
    ...................................................................................................
    ...................................................................................................

    Penerima Ponorogo,............................ Pengirim


    Jam : ...........................

    (..............................................................) (.................................................................)

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    ANALISA DATA

    Nama : ......................................................... Jenis Kelamin : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................
    Alamat : ......................................................... Diagnosis : ........................................................

    No Data Masalah Etiologi

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018


    RENCANA KEPERAWATAN

    Nama : ........................................................ Jenis Kelamin : ........................................................


    Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................
    Alamat : ........................................................ Diagnosa : ........................................................

    No Diagnosa Keperawatan Tujuan dan Kriteria Hasil Intervensi

    KELOMPOK 3 | PROFESI NERS UNMUH PONOROGO 2018

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