YAYASAN WIDYA MANDALA SURABAYA

UNIVERSITAS KATOLIK WIDYA MANDALA SURABAYA

FAKULTAS KEPERAWATAN
Jl. Raya kalisari selatan No.1, lantai 8, Tower B, Pakuwon City, Surabaya
Telp. (031) 99005299, ext (10853), fax. (031) 99005278
Email: keperawatan@mail.wima.ac.id fkep.wima@yahoo.co.id Website: http//www.wima.ac.id

NURSING ASSESSMENT

Information from : Patient Family, Relationship : Other person

STICKER Date of hospitalized:

Date of assessment :
Medical diagnosis :
Unit from :
URJ OK ICU Others…….
UGD
Tribe :
Religion : Way in patient room : Walk Wheel chair
Education : Brankar Others……
Job :
Address :
Phone number :
Main Complaint :………………………………………………………………………..………….…

Current Disease Record :……………………………………………………………………….…… .

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………

Disease has been suffered :………………………………………………………………….…………

…………………………………………………………………………………………………………………

Medical History :
Name of Drugs Way to take Frequency Last Time Given
Nursing History

Family Diesease History :…………………………………………..…………………………………

Alergy : Drugs (Kind :……….) Don’t Know

Food (Kind :………..) Others
Dust
Reaction :………………………………………………
History of blood transfusion: Yes No Reaction :……………..
History of Smoke : Yes No
History of Alcohol : Yes No
History of Operation : Yes No
Complications :…………………..
Physical Examination
General awareness: Good Netral Weak
C
Awareness : Compos mentis Apatis somnolen sopor coma
GCS : Eye :………. Verbal:………….Motorik:…………..Total:……………
Vital sign : BP :………..mmHg
HR :………..x/mnt, Location :……………., Pulse :…………………
Temp :………….ºC
RR :………….x/mnt
Weight :……….kg Height :…………..cm Upper arm Circumference :…………..cm
 Breath Patterns :Rhythm: Teratur Tidak teratur
C C
Kind : Dispnea Kusmaul Cheyne stokes Others
C C C C
Breath Sounds : C
Vesikuler C
Right C
Left
C Wheezing C Right CLeft
C Ronchi C Right C Left
C Weak C Right CLeft
B1 – Breathing

C Disappeared C Right C Left

Out of Breath : C Yes C No
Breath Aids Muscles : Yes ,Kind………….. No
C C
Cough : Yes C No
Sputum Production : C Yes, Color :………… Consistency :……………. C No
Chest Movement : Symmetrical Asymmetric
WSD : Yes No Location :…….. Production :………..Color :……….
Breath Aids : : Yes No kind :…….. Flow :………..lpm :……….
Others :……………………………………………………………….

Hearth Rhythm : :C Reguler C Ireguler

S1/S2 : Yes No, Explain :

B2 – Bleeding

Chest Pain : Yes No

Hearth Sounds : C Normal C Murmur C Gallop Other
C
CRT : < 3scn > 3 scn
Akral : Warm C Hot CCold, Dry C Cold Wet
Distention jugular vein
C : Yes No
Cyanosis : Yes No
Others : ………………………………………………………
Physiological Reflex : Patella Triseps Biseps Others :
C C C
Pathological Reflex : C Babinsky CBrudzinsky C Kerning Others :
Dizzy : C Yes No
C C
C
Vision (Eyes)
Pupil : Isokor C Anisokor Size :……….. mm
C
Light Reflex (Ri/Le) :…./….
Diameter (Ri/Le) :…..mm/…..mm
Sklera / Konjungtiva : anemis Cikterus COthers:
C
Vision : CNormal CBlur CGlasses CContact Lens
B3 – Braim: persyarafan

Hearing (Ears) : Clean C Dirty (Ri/Le) C Tinitus (Ri/Le) C Otitis media (Ri/Le)
C
Hearing disorders : C Yes C No Explain :…………….

Smell (Nose) : CGood CClogged up Slime Epitaksis

C C
Form : C Normal No Explain :……………..
C
Olfactory Disorders : C Yes C No Explain :……………..

Sleep Patterns : Normal Hard to Sleep Often Wake Up

C C C
Rest/Sleep : ……………….Hours/day
Others :…………………………..

Pain Assessment
Originator Quality Location/ Scale Time Causes of pain
Radiation (0-10) disappear or decrease
 Universal Pain Tool

0 2 4 6 8 10
Not pain Very Mild Moderate Pain Great Pain Very Painful Cannot be
Pain disclosed

Pain Affects :
C Could be ignored C Task C Concentration
C Sleep C Physical Activity C Appetite
Hygien : C clean dirty
C
B4 – Bladder: Perkemihan

Urine : Total :………cc/hari colour :………….. Smell :……………

Chateter : type :………….. Start :…………...
Bladder : enlarged Yes No
C C
Tendernessn Yes No
C
Distrubtance : Normal C Anuria C Oliguria C Retention
C Nokturia C
Inkontinensia
C
Hematuria
C
Etc:…………
Intake oral fluid :…………………cc/hariC
Etc :…………………………
C
Appetite. : Good reduce Frequency:…………………..x/day
C C C
C Nursea vomiting
C
Portion of eating : Run out Don't run out explaintation:………………
Diet. :………………………. Fovorite food :……………….
CNo C
Changes of weight : Yes , estimate………….kg/month/week
Equirtment for help eating : Nothing NGT, start…………….
Drink : …………..cc/day Type: …………….
C C
Mouth and throat
B5 – Bowel: Pencernaan

C C smelling
Mouth : C Clear Dirty
C C
Mucusa : moist dry. C
Stomatitis
Throat. : C pain swallow Disfagya
enlarge tonsil Etc :

Abdomen : C Normal C rigid. Bloated. Acites C

pulse pain, Location ………
Peristaltic :……………..x/minute
Enlargement liver : Yes No
C CC
Enlargement limfe : yes No
Defication. : ……..x/day. Regular : Yes. No
C
Last date :………….
C Hemoroid MelenaC
C C
Consistency: …………….. Smell……………….. Colour:……………
Etc :……………………………….
C C

C C

C C
 Joint Movement Ability : Independent Limit
C C
: Muscle scale :

Fracture : Yes No Location:………………

C C
Decubitus : No Yes, Location:………………, degre ::……………..
C C
Wound : No. Yes, Location…… Pus: Yes No
C C C C
Wound burns : Yes No
C C
B6 – Bone and Muskuloskeletal/Integument

Skin : Normaly Wound Bruises Dry Itchy

C C C C C
C Scaly
Skin Color : Ichterus Cyanosis C Reddish Pale CHyperpigmentation
C C C
C Petekie
Akral : C Warm Dingin merah
C
C Dry C Moist CPale
Turgor : C Good C
Medium C
Bad
Odeme : C No C
Yes Location……………….

Using aids : Traction Gips Location:………………

C C
Others :………………………………………………………………

Enlargement of thyroid gland : CYa Tidak

C
Endokrin

Enlarged lymph nodes : CYa Tidak

C
Gangrenous wounda : Yes, Location :……………… Tidak
C C
Lain – lain :……………………………………………………………………..

Persepsi pasien terhadap penyakitnya : C Cobaan tuhan CHukuman Lainnya, Sebutkan

C
…………………………………………………………..
Ekspresi pasien terhadap penyakitnya : CRendah diri C Gelisah
Psiko- sosio- spiritual

C Marah/menangis C Tenang

Orang yang paling dekat :……………………………………………………………………..

Hubungan dengan teman dan lingkungan sekitar : …………………………………………….
Kegiatan ibadah
Sebelum sakit : Sering Kadang-kadang Jarang
C C C
Selama sakit : Sering Kadang-kadang Jarang
C C C
Lain- lain :……………………………………………………………………………..
 Diagnosis keperawatan :
1.
2.
3.
4.
5.
Laboratorium Foto/ Radiologi USG Lain-lain
Pemeriksaan penunjang dan Terapi

Terapi/ Tindakan medis :

1.
2.
3.
4.
5.

Surabaya…………………

Dokter Perawat

(…………………………) (…………………………)

Nama Terang Nama Terang