PANDUAN PENGKAJIAN ASUHAN KEPERAWATAN

PRAKTEK PROFESI KEPERAWATAN INTENSIVE

PSSKPN FK UNUD

A. PENGKAJIAN

Tgl/ Jam : ……………………… No. RM : ………………………………….

Ruangan : ………………………. Diagnosis Medis : ………………………………….

Nama/Inisial : ………………….. Jenis Kelamin : ………………………

Umur : ………………….. Status Perkawinan : ………………………
IDENTITAS

Agama : ………………….. Sumber Informasi : ………………………

Pendidikan : …………………... Hubungan : ………………………
Pekerjaan : …………………...
Suku/ Bangsa : ..………………….
Alamat : ……………………

Keluhan utama saat MRS :

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Keluhan utama saat pengkajian :
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Riwayat penyakit saat ini :
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Riwayat Alergi :
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Riwayat Pengobatan :
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Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga:
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Jalan Nafas :  Paten  Tidak Paten

BREATHING

Obstruksi :  Lidah  Cairan  Benda Asing  Tidak Ada

 Muntahan  Darah  Oedema
Suara Nafas: Snoring Gurgling Stridor Tidak ada
Nafas :  Spontan  Tidak Spontan
Gerakan dinding dada:  Simetris  Asimetris
Irama Nafas :  Cepat  Dangkal  Normal
Pola Nafas :  Teratur  Tidak Teratur
Jenis :  Dispnoe  Kusmaul  Cyene Stoke  Lain… …
Suara Nafas :  Vesikuler  Stidor  Wheezing  Ronchi
Sesak Nafas :  Ada  Tidak Ada
Cuping hidung  Ada  Tidak Ada
Retraksi otot bantu nafas :  Ada  Tidak Ada
Pernafasan :  Pernafasan Dada  Pernafasan Perut
Batuk :  Ya  Tidak ada
Sputum:  Ya , Warna: ... ... ... Konsistensi: ... ... ... Volume: ... … Bau: … …
 Tidak
RR : ... ... x/mnt
Alat bantu nafas:  OTT  ETT  Trakeostomi
 Ventilator, Keterangan: ... ... ...
Oksigenasi : ... ... lt/mnt  Nasal kanul  Simpel mask  Non RBT mask  RBT Mask  Tidak
ada
Lain:
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Masalah Keperawatan:

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Nadi :  Teraba  Tidak teraba  N: … …x/mnt
Tekanan Darah : … … mmHg
Pucat :  Ya  Tidak
Sianosis :  Ya  Tidak
CRT :  < 2 detik  > 2 detik
Akral :  Hangat  Dingin  S: ... ...C
Pendarahan :  Ya, Lokasi: ... ... Jumlah ... ...cc  Tidak
Turgor :  Elastis  Lambat
Diaphoresis:  Ya Tidak
BLOOD

Riwayat Kehilangan cairan berlebihan:  Diare  Muntah  Luka bakar

IVFD :  Ya  Tidak, Jenis cairan: … …
Lain:
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Masalah Keperawatan:
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Kesadaran:  Composmentis  Delirium  Somnolen  Apatis  Koma
GCS :  Eye ...  Verbal ...  Motorik ...
Pupil :  Isokor  Unisokor  Pinpoint  Medriasis
Refleks Cahaya: Ada  Tidak Ada
Refleks fisiologis:  Patela (+/-)  Lain-lain … …
Refleks patologis :  Babinzky (+/-)  Kernig (+/-)  Lain-lain ... ...
Refleks pada bayi:  Refleks Rooting (+/-)  Refleks Moro (+/-)
(Khusus PICU/NICU)  Refleks Sucking (+/-) 
BRAIN

Bicara :  Lancar  Cepat  Lambat

Tidur malam : … … jam Tidur siang : … … jam
Ansietas :  Ada  Tidak ada
Lain : ...........................................................................................................................................
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Masalah Keperawatan:
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 Nyeri pinggang:  Ada  Tidak
BAK :  Lancar  Inkontinensia  Anuri
Nyeri BAK :  Ada  Tidak ada
BLADER Frekuensi BAK : … … Warna: ... ... Darah :  Ada  Tidak ada
Kateter :  Ada  Tidak ada, Urine output: ... ...
Lain: ...........................................................................................................................................

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Masalah Keperawatan:
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TB : ... ...cm BB : ... ...kg
Nafsu makan :  Baik  Menurun
Keluhan :  Mual  Muntah  Sulit menelan
Makan : Frekuensi ... ...x/hr Jumlah : ... ... porsi
Minum : Frekuensi ... ... gls /hr Jumlah : ... ... cc/hr
Perut kembung :  Ya  Tidak
BAB :  Teratur  Tidak
BOWEL

Frekuensi BAB : ... ...x/hr Konsistensi: ... ... .. Warna: ... ... darah (+/-)/lendir(+/-)
Lain :
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Masalah Keperawatan:
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Nyeri :  Ada  Tidak
(Muskuloskletal & Integumen) BONE

Problem : ... ... Qualitas/ Quantitas : ... ...

Regio : ... ... Skala : ... ...
Timing : ... ...
Kekuatan otot : ... ...

Deformitas  Ya
:  Tidak  Lokasi ... ...
Contusio  Ya
:  Tidak  Lokasi ... ...
Abrasi  Ya
:  Tidak  Lokasi ... ...
Penetrasi  Ya
:  Tidak  Lokasi ... ...
Laserasi  Ya
:  Tidak  Lokasi ... ...
Edema  Ya
:  Tidak  Lokasi ... ...
Luka Bakar  Ya
:  Tidak  Lokasi ... ...
Grade : ... ... % Keterangan:
Jika ada luka/ vulnus, kaji: 0; Mandiri
1; Alat bantu
Luas Luka : ... ... 2; Dibantu orang lain
Warna dasar luka: ... ... 3; Dibantu orang lain &
Kedalaman : ... ... alat
4; Tergantung total
Aktivitas dan latihan :0 1 2 3 4
Makan/minum :0 1 2 3 4
Mandi :0 1 2 3 4
Toileting :0 1 2 3 4
Berpakaian :0 1 2 3 4
Mobilisasi di tempat tidur :  0 1 2 3 4
Berpindah :0 1 2 3 4
Ambulasi :0 1 2 3 4
Lain-lain :
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Masalah Keperawatan:
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 (Fokus pemeriksaan pada daerah trauma/sesuai kasus non trauma)
Kepala dan wajah :
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Leher :
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Dada :
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HEAD TO TOE

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Abdomen dan Pinggang :
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Pelvis dan Perineum :
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 Ekstremitas :
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Masalah Keperawatan:
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Hasil laboratorium (TGL):………………………………………….
Jenis
Pemeriksaan No Parameter Satuan Nilai Rujukan Hasil Interpretasi
TEST DIAGNOSTIK DAN TERAPI MEDIS
Terapi medis saat ini (TGL): …………………………………………………………………….
Tanggal Nama Obat Dosis Rute Fungsi

Masalah Keperawatan:
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