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LAPORAN KASUS LENGKAP

PROGRAM PROSFESI NERS PSIK FK UNSRI


KEPERAWATAN GAWAT DARURAT DAN INTENSIF
FORMAT PENGKAJIAN
I. IDENTITAS KLIEN

Tanggal Pengkajian:

Nama

: ..........................................................................................................

.....
Umur

: ..........................................................................................................

.....
Jenis

Kelamin
: ..........................................................................................................

.....
Status

Marital
: ..........................................................................................................

.....
Agama

: ..........................................................................................................

.....
Suku

Bangsa
: ..........................................................................................................

.....
Pendidikan

: ..........................................................................................................

.....
Pekerjaan

: ..........................................................................................................

.....
Tanggal

Masuk

RS

: ..........................................................................................................
.....
Keluarga yang dapat segera dihubungi (Orangtua/Wali, Suami, Istri, dll)
Nama
: ..........................................................................................................
.....
Pendidikan

: ..........................................................................................................

.....
Pekerjaan

: ..........................................................................................................

.....
Alamat

: ..........................................................................................................

.....

No.

Telp
: ..........................................................................................................

II.

.....
STATUS KESEHATAN SAAT INI
1. Keluhan Utama
:
.
........................................................................................................................................
........................................................................................................................................
........
2. Riwayat Penyakit Sekarang :
.

3. Riyawat Penyakit Dahulu

....................................................................................................................................
........
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....
III.

RIWAYAT BIOLOGIS
1 Pola nutrisi
Sebelum

sakit

: ..................................................................................................... ..................
....................................................................................................................
Setelah
sakit
: ..................................................................................................... ..................
..................................................................................................................
2 Pola eliminasi
Sebelum

sakit

: ..................................................................................................... ..................
.................................................................................................................................
.........................................................................................................................
Setelah
sakit
: ..................................................................................................... ..................

..................................................................................................................................
3

........................................................................................................................
Pola tidur dan istirahat
Sebelum
sakit
: ..................................................................................................... ..................
....................................................................................................................
Setelah
sakit
: ..................................................................................................... ..................

....................................................................................................................
Pola aktivitas dan latihan
Sebelum

sakit

: ..................................................................................................... ..................
....................................................................................................................
Setelah
sakit
: ..................................................................................................... ..................
5

....................................................................................................................
Pola bekerja
Sebelum

sakit

: ..................................................................................................... ..................
....................................................................................................................
Setelah
sakit
: ..................................................................................................... ..................
...................................................................................................................

IV.

RIWAYAT KELUARGA (GENOGRAM)


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V.

........................................................................
ASPEK PSIKOLOGIS
Pola pikir dan persepsi
a. Alat bantu yang digunakan :
....
b. Kesulitan yang dialami
:

Persepsi diri
a. Hal yang dipikirkan saat ini :
....
b. Harapan
setelah
menjalani

c. Perubahan
yang
dirasa

perawatan

setelah

sakit

sendiri

kehidupan

...
Suasana hati
:

Pertahanan koping
a. Pengambilan keputusan
:
....
b. Yang
disukai
tentang
diri

c. Yang
ingin
dirubah
dari

d. Yang dilakukan jika stress :

Hubungan/komunikasi :
.
Sistem nilai kepercayaan
a. Siapa
atau
apa
sumber
kekuatan
...
b. Apakah
Tuhan,
agama,
kepercayaan
penting

untuk

:
anda

c. Kegiatan

agama/kepercayaan

yang

ingin

dilakukan

di

RS

..
VI.

PENGKAJIAN FISIK DARI HEAD TO TOE


(FOKUS DAN SESUAIKAN DENGAN PENYAKITNYA)
KEADAAN UMUM
TB
:
BB
:
Tekanan Darah :
SISTEM NEUROLOGI
Kesadaran
:
..
GCS
:
..
Refleks
: ............................................................................................................
.....
Riwayat

epilepsi

kejang :........................................................................................................
Refleks
: ............................................................................................................
.....
Trauma
: ............................................................................................................
.....
SISTEM PENGLIHATAN
Bentuk
:
..
Visus OD/OS
:
..
TIO
:
.
Palpebra
:
..
Pupil
(bentuk,
ukuran
letak,
reflek
..
Konjungtiva
:
..
Akomodasi
:
......
Lensa
:
..

cahaya)

Tanda Radang

..
Alat bantu
:
..
Riwayat Oprasi
:
..
SISTEM PENDENGARAN
Reaksi Alergi
:
..
Keluhan
:
..
..................................................................................................
.....
..................................................................................................
.....
..................................................................................................
.....
SISTEM PERNAPASAN
Pola Napas
:
.
Suara Napas
:
.
Sesak
:

Batuk
:
.
Sputum
:
.
Nyeri
:

Trauma dada
:
................
:
.
:
.
: ...................................................................................................
....
: ...................................................................................................
....
SISTEM KARDIOVASKULER

HR

: ...................................................................................................

.....
Capilary

Refilling
: ...................................................................................................

.....
JVP
.....
Suara

: ...................................................................................................
Jantung
: ...................................................................................................

.....
Edema
:....................................................................................................
.....
Nyeri
:....................................................................................................
.....
Palpitasi
:....................................................................................................
.....
BAAL
.....
Perubahan

:....................................................................................................
warna

kulit

:....................................................................................................
.....
Kuku
:....................................................................................................
.....
Clabbing

finger
: ...................................................................................................

....
Akral

Dingin
:....................................................................................................

.....
SISTEM PENCERNAAN
NUTRISI
Intake
: ...................................................................................................
.....
: ...................................................................................................
.....

: ...................................................................................................
.....
: ...................................................................................................
.....
Output
: ...................................................................................................
.....
: ...................................................................................................
.....
: ...................................................................................................
.....
: ...................................................................................................
.....
: ...................................................................................................
.....
Nafsu

Makan
:....................................................................................................

.....
Jenis

Diet
:....................................................................................................

.....
Mual

muntah
:....................................................................................................

.....
ELIMINASI
BAB

:....................................................................................................

.....
BAK

:....................................................................................................

.....
Keluhan/gangguan

:....................................................................................................

.....
.....................................................................................................
.....
.....................................................................................................
.....
.....................................................................................................
.....
Kateter
:....................................................................................................
.....
SISTEM REPRODUKSI

GPA

...
Perdarahan
:
.
:
.
:
.
Keluhan
:
.
:

:
.
:
.
SISTEM MUSKULOSKELETAL
Nyeri
:
.
Gangguan persendian :
.
ROM
:
.
Pergerakan ekstremitas :
.
.....................................................................................................
....
Kekuatan otot

.
:
.
:
.
SISTEM INTEGUMEN
Warna
: ...................................................................................................
.....
Integritas
.....

: ...................................................................................................

Turgor
: ...................................................................................................
.....
VII.
DATA PENUNJANG/ LABORATURIUM
a. Laboratorium
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b. Pemeriksaan diagnostik lainnya
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VIII.

........................................
TERAPI SAAT INI
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