JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN NON TRAUMA

Nama Mahasiswa

Tempat Praktik

NIM

Tgl. Praktik

1. Identitas Klien
Nama

:.......................................... No. RM

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

Usia

:............. tahun

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

Jenis kelamin

:.......................................... Tgl. Pengkajian

Alamat

:.......................................... Sumber informasi :.........................................

Status pernikahan

:.......................................... Agama

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

Suku

:.......................................... Pendidikan

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

Pekerjaan

:.......................................... Dx.Medis

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

Tgl. Masuk

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

2. Status kesehatan Saat Ini

1. Keluhan utama MRS

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2. Riwayat kesehatan sebelumnya

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3. Data Obyektif
Airway
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Breathing
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Circulation
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Disability
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Full set of vital sign

Tekanan darah : mmHg

Suhu
:oC
Nadi
:... x/menit
RR
: x/menit

Five Intervention
Monitor Irama dan rate jantung : ...................................................................................................
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Pasang pulse oximetri : .................................................................................................................
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Pasang kateter urine : ...................................................................................................................
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Pasang NGT : ...............................................................................................................................
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Pemeriksaan Lab : ........................................................................................................................
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Head to toe examination

1. Kepala & Leher

a. Kepala:
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b. Mata:
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c. Hidung:
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d. Mulut & tenggorokan:
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e. Telinga:
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f. Leher:
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2. Thorak & Dada:
Jantung
- Inspeksi:..................................................................................................................................
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- Palpasi:...................................................................................................................................
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- Perkusi:...................................................................................................................................
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- Auskultasi:..............................................................................................................................
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Paru
- Inspeksi:..................................................................................................................................
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- Palpasi:...................................................................................................................................
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- Perkusi:...................................................................................................................................
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- Auskultasi:.................................................................................................................................
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3. Payudara & Ketiak
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4. Punggung & Tulang Belakang
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5. Abdomen
Inspeksi:........................................................................................................................................
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Palpasi:..........................................................................................................................................
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Perkusi:..........................................................................................................................................
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Auskultasi:.....................................................................................................................................
6. Ekstermitas
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7. Genetalia
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8. Sistem Neurologi
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10. Kulit & Kuku
Kulit:
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Kuku:
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4. Hasil Pemeriksaan Penunjang

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5. Terapi
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