Professional Documents
Culture Documents
A. Identitas Klien
Nama : …………………………………. Suami/Istri/Orang Tua :
Umur : …………………………………. Nama : ……………………..
Jenis Kelamin : …………………………………. Pekerjaan : ……………………..
Agama : …………………………………. Alamat : ……………………..
Suku/Bangsa : …………………………………. ……………………...
Bahasa : ………………………………….
Pendidikan : ………………………………….
Pekerjaan : ………………………………….
Status : ………………………………….
Alamat : ………………………………….
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→ Obyektif
2. Tanda-tanda Vital
Tekanan Darah : ……………………. mmHg
Nadi : …………………….. x/menit, Kelaianan : …………………….
Respiratory Rate : …………………….. x/menit, Pola Napas : …………………….
Suhu : ……………………... 0C
C. Kasus Trauma
→ Subyektif
1. Keluhan Utama
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2. Mekanisme Trauma
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3. SAMPLE (symptom, allergy, medications, past illness, last meals, event)
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→ Obyektif
1. Airway
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2. Breathing
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3. Circulation
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4. Disability
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5. Exposure/Environtmental Control
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6. Full Set Of Vital Sign / Five Interventions
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7. Give Comfort
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8. Head To Toe Assesment
I. Kepala
i. Bentuk Kepala
Simetris Asimetris Dolikhosefalus
Brakhiosefalus Hidrosefali Mikrosefali
ii. Kulit Kepala
Luka Benjolan Tidak ada kelainan
iii. Rambut
Alopesia Penyebaran Tidak Merata
Berbau Kotor tidak ada kelaian
iv. Wajah
Pucat Kemerahan Asimetris
Simetris Sembab Tidak ada kelainan
v. Ubun-ubun
Datar Cekung Cembung
terdapat benjolan Tidak ada kelaianan
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vi. Lain-lain
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II. Mata
i. Mata
Semetris Asimetris
ii. Kelopak mata
Edema Lesi Peradangan
Benjolan Ptosis Ektropion
Entropion Bulu mata rontok Brill Hematom
iii. Konjungtiva
Anemis Kemerahan Tidak ada kelainan
iv. Sklera
Icterus Kemerahan Tidak ada kelainan
v. Pupil
Reflek cahaya : Langsung : Positif Negatif
Konsensual : Positif Negatif
Diameter : Isokor Anisokor
Miosis Midriasis
vi. Kornea dan Iris
Terdapat lesi Terdapat tanda peradangan
vii. Pergerakan bola mata
Keenam arah Kelainan....................................................
viii. Lain-lain
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III. Hidung
i. Tulang hidung dan posisi septum nasi
Terdapat deviasi Tidak ada kelainan
ii. Lubang hidung
Rinorea Sumbatan
Mukosa : Kering Basah Lembab
iii. Lain-lain
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IV. Telinga
i. Bentuk telinga
Simetris Asimetris
ii. Lubang telinga
Ototea Corpus alienum
iii. Prosesus mastoideus
Nteri tekan Battle sign
iv. Lain-lain
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V. Mulut dan Faring
i. Bibir
Sianosis Jejas
Kering basah
ii. Gigi dan Gusi
Perdarahan Gigi lepas
iii. Lidah
Warna merah merata Kotor
Luka Bercak-bercak putih
iv. Rongga Mulut
Napas berbau Peradangan Luka
Sekret Perubahan fonasi
v. Lain-lain
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VI. Leher
i. Trakea
Simetris Deviasi Pembesaran kel. tiroid
ii. Vena jugularis
Distensi Tidak ada kelainan
iii. Lain-lain
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VII. Thorax / Paru
i. Bentuk
Normal chest Pigeon chest Funnel chest
Barrel chest Kifosis Skoliosis
ii. Pernapasan
Dyspnea Retraksi intercosta
Retraksi supra sternal Pernapasan cuping hidung
Sianosis Pola napas .....................................
iii. Suara napas
Bronkial Bronkovesikuler Vesikuler
Ronchi Whezing Friction rubs
Stridor Gurgling
iv. Perkusi
Sonor Redup Pekak
Hipersonor Timpani
v. Palpasi (fremitus)
Kanan = Kiri Kanan >> Kiri >>
vi. Lain-lain
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VIII. Jantung
i. Inspeksi
Pulsasi jejas
ii. Palpasi ictus cordis
Tidak teraba Teraba di.................................diameter...........cm
iii. Suara jantung
BJ I & II tunggal Bising/Mur-mur
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iv. Perkusi
Batas jantung normal Kardiomegali
v. Lain-lain
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IX. Abdomen
i. Bentuk abdomen
Flat Scapoid Rounded
Protuberans Spyder navy
ii. Peristaltik usus
Tidak ada Ada, ...........................x/menit
iii. Benjolan/massa pada abdomen
ada Tidak ada Nyeri tekan
iv. Turgor kulit
Normal Menurun
v. Perkusi
Sonor Redup Pekak
Timpani Shifting dullness Undulasi
vi. Lain-lain
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X. Ektremitas
i. Tulang
Simetris Asimetris
ii. Range of Motion
Terbatas Tidak terbatas
iii. Palpasi
Pitting edema Non pitting edema
Krepitasi Nyeri tekan
Hangat Dingin
Lembab Kering
iv. Jejas
Contusio Abratio Laserasi
v. Kekuatan otot
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vi. Tanda-tanda fraktur
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vii. Lain-lain
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XI. Pelvis dan Genetalia
Jejas Benjolan Luka
Pembengkakan Perdarahan Hematuria
Lain-lain ..................................................................................................
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9. Inspect Posterior Surface
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D. Pemeriksaan Penunjang
1. Laboratorium
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2. Radiologi/USG/CT-Scan/MRI
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3. Elektrokardiografi
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NIM.