PENGKAJIAN KEPERAWATAN INTENSIF

No. RM

Ruangan

Diagnosis Medis

RIWAYAT SAKIT DAN KESEHATAN

IDENTITAS

Tgl/ Jam

Nama/Inisial

Jenis Kelamin

Umur

Status Perkawinan

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 Allergi

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Riwayat Pengobatan

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Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga:
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BREATHING

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Jalan Nafas : Paten
Tidak Paten
Obstruksi

: Lidah
Muntahan

Suara Nafas: Snoring

Nafas

Cairan

Benda Asing

Darah

Oedema

Gurgling

Stridor

: Spontan

Tidak Ada

Tidak ada

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

Cuping hidung Ada

Tidak Ada
Tidak Ada

Retraksi otot bantu nafas : Ada Tidak Ada

Pernafasan : Pernafasan Dada
Batuk

: Ya

Pernafasan Perut

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
Mask

Tidak ada

Lain:

MasalahKeperawatan:

RBT

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Nadi
: Teraba
Tidak teraba
N: x/mnt

BLOOD

TekananDarah : mmHg
Pucat

: Ya

Tidak

Sianosis

: Ya

Tidak

CRT

: < 2 detik

> 2 detik

Akral

: Hangat

Dingin

Pendarahan

: Ya, Lokasi: ... ... Jumlah ... ...cc

Turgor

: Elastis

S: ... ...C
Tidak

Lambat

Diaphoresis: Ya

Tidak

Riwayat Kehilangan cairan berlebihan: Diare Muntah Luka bakar

IVFD : Ya Tidak, Jenis cairan:
Lain: ... ...
MasalahKeperawatan:
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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 ... ...

BRAIN

Refleks pada bayi: Refleks Rooting (+/-) Refleks Moro (+/-)

(Khusus PICU/NICU) Refleks Sucking (+/-)
Bicara : Lancar Cepat

Lambat

Tidur malam : jam Tidur siang : jam

Ansietas : Ada Tidak ada
Lain :
MasalahKeperawatan:
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Nyeri pinggang: Ada

BAK : Lancar

Tidak

Inkontinensia

Anuri

BLADDER

Nyeri BAK : Ada Tidak ada

Frekuensi BAK : Warna: ... ... Darah : Ada

Tidak ada

Kateter : Ada Tidak ada, Urine output: ... ...

Lain: ... ...
MasalahKeperawatan:
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TB : ... ...cm BB : ... ...kg
Nafsu makan : Baik Menurun
Keluhan : Mual

Muntah

Sulit menelan

Makan : Frekuensi ... ...x/hr Jumlah : ... ... porsi

BOWEL

Minum : Frekuensi ... ... gls /hr Jumlah : ... ... cc/hr
Perut kembung : Ya

Tidak

BAB : Teratur Tidak

Frekuensi BAB : ... ...x/hr Konsistensi: ... ... .. Warna: ... ... darah (+/-)/lendir(+/-)
Lain : ... ...
MasalahKeperawatan:
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(Muskuloskletal & Integumen) BONE

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Nyeri : Ada
Tidak
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 : ... ... %

Jika ada luka/ vulnus, kaji:
Luas Luka

: ... ...

Warna dasar luka: ... ...

Kedalaman : ... ...
Aktivitas dan latihan

:0

Makan/minum

:0

Mandi

:0

Toileting

:0

Berpakaian

:0

Mobilisasi di tempat tidur : 0

Berpindah

: 0

Ambulasi

: 0

Keterangan:
0; Mandiri
1; Alatbantu
2; Dibantu orang lain
3; Dibantu orang lain & alat
4; Tergantung total

Lain-lain : ... ...

MasalahKeperawatan:
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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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TEST DIAGNOSTIK DAN TERAPI MEDIS

Hasil laboratorium (TGL):

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Terapi medis saat ini (TGL):
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Masalah Keperawatan:
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