INITIAL ASSESSEMENT

GUIDELINES
Achmad Sigit S

11/8/2018 Semilokakarya Aplikasi Dokumentasi

Keperawatan RSUD dr. Soebandi
 Respiratory

 Rate, depth, characters (ronchi,

rales, wheezing, etc), dyspnea,
symmetry of chest movement,
breath sounds, secretions,
cough, incision, dressings,
oxygen therapy, chest tube,
ventilator setting if available
 Circulatory
 Skin color, temperature,
capillary refill time, heart
sounds, pulse rate, rhythm,
ECG pattern if available, skin
turgor, edema, neck vein
distension, hemodynamic
pressures if available, blood
pressure, intravenous therapy
(with counts), incision,
dressings
 Neurological
 Level of consciousness, Glasgow
Coma Scale, verbal response, pupil
size and reaction to light, eye ball
movement; Orientation to man,
place and time; seizures, reflexes,
incision or head dressing, intra
cranial monitor, sensory or mobility
deficits, hearing deficits
 Gastrointestinal

 Shapeand feel of abdomen,

Bowel sounds, tenderness,
nausea, emesis, diet and intake,
dysphagia, bowel movement,
nasogastric tube/tube feeding,
ostomy site, stoma, drainage
and care, incision, dressing
 Genitourinary

 Urinaryoutput, continence,
appearance of urine, folley
catheter status
 Musculoskeletal

 Mobility limitation, extremity status,

cast or traction, incision, dressing
 Support therapy

 Wound drains, irrigation, WSD,

invasive lines, pain control
measure (transelectrical nerve
stimulation, patient-controlled
analgesia pump), etc.