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DOKUMENTASI

ASUHAN KEPERAWATAN KRITIS

Pengkajian di ambil tanggal : ............................................


Tanggal masuk
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Ruang/kelass
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No. Kamar
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Diagnosa masuk
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I.

IDENTITAS
Nama
Umur
Jenis kelamin
Agama
Suku/bangsa
Bahasa
Pendidikan
Pekerjaan
Alamat
Penanggung jawab

Pukul : ...........................................
Reg. : ...........................................

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: ............ tahun
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II. RIWAYAT SEBELUM SAKIT


Penyakit berat yang pernah diderita
Obat yang biasa dikonsumsi

Kebiasaan berobat
Alergi obat atau makanan
Alat bantu yang digunakan

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III. RIWAYAT PENYAKIT SEKARANG


Keluhan utama
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Tangggal mulai sakit
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Proses terjadinya sakit :
tiba-tiba
berangsur-angsur
Faktor pencetus
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Upaya yang dilakuakan : ...................................................................................................................
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Tanda-tanda vital
: TD : .......................mmHg N : ................x/menit
S : ......................0C
RR : ................x/menit
IV. RIWAYAT KESEHATAN KELUARGA
Riwayat yang pernah diderita oleh anggota keluarga
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Penyakit yang pernah diderita oleh anggota keluarga

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V. PENGKAJIAN SISTEM
1. Sistem pernafasan (B1)
Data subjektif : ..............................................................................................................................
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Data objektif
Inspeksi
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Auskultasi : ...............................................................................................................................
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Palpasi
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Perkusi
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2. Sistem kardiovaskuler (B2)
Data subjektif : ..............................................................................................................................
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Data objektif
Inspeksi
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Auskultasi : ...............................................................................................................................
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Palpasi
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Perkusi
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3. Sistem neurologi (B3)
Data subjektif : ..............................................................................................................................
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Data objektif
Inspeksi
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Auskultasi : ...............................................................................................................................
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Palpasi
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Perkusi
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4. Sistem perkemihan (B4)
Data subjektif : ..............................................................................................................................
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Data objektif
Inspeksi
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Auskultasi : ...............................................................................................................................
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Palpasi
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Perkusi
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5. Sistem pencernaan (B5)


Data subjektif : ..............................................................................................................................

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6.

7.

8.

9.

Data objektif :
Inspeksi
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Auskultasi : ...............................................................................................................................
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Palpasi
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Perkusi
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Sistem muskuloskeletal (B6)
Data subjektif : ..............................................................................................................................
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Data objektif :
Inspeksi
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Auskultasi : ...............................................................................................................................
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Palpasi
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Perkusi
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Sistem lain yang terkait
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Pola istirahat
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Pola personal hygiene
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VI. PSIKOSOSIAL
Sosial/interaksi : ...............................................................................................................................
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Konsep diri
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Spiritual
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VII. TINDAKAN MEDIS dan OBAT YANG DIBERIKAN
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VIII. PEMERIKSAAN PENUNJANG
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Bitar,......................................
Perawat

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