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Format Pengkajian Keperawatan Gadar

Format Pengkajian Keperawatan Gadar

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Dipublikasikan oleh Anisa Rooses

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Published by: Anisa Rooses on Dec 25, 2010
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07/17/2013

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PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN KRITIS
STIKES HANG TUAH SURABAYA
Nama mahasiswa : ………………………………………………………………………………….....
NIM : ………………………………………………………………………………….....
Ruangan : ………………………………………………………………………………….....
Pengkajian diambil : ………………………………………………………………………………….....
Diagnosa medis : ………………………………………………………………………………….....
A. IDENTITAS PASIEN
Nama : ………………………………………………………………………………….....
Umur : ………………………………………………………………………………….....
Jenis kelamin : .................................................................................................................................
Suku : .................................................................................................................................
Agama : .................................................................................................................................
Pendidikan : .................................................................................................................................
Alama : .................................................................................................................................
B. RIWAYAT KEPERAWATAN
!eluhan uama ......................................................................................................................................
Riwa"a #en"aki sekarang $RPS%
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
Riwa"a #en"aki dahulu $RPD%
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
Riwa"a kesehaan keluarga
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
&enogram
C. PENGKAJIAN PERSISTEM
!eadaan umum
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
'anda(anda )ial
*P……………………………. mm+g
+R……………………………. ,-mn. irama ………………… Pulsasi…………………
RR……………………………. ,-mn. irama ………………….
………………………………./0
*reah $*1% Pergerakan dada 2 Simeris 2 Asimeris
Pemakaian oo
banu na#as
2 ada. Jenis : ……………
2 'idak ada
Suara na#as 2 3esikuler 2 rhonki
2 whee4ing
5okasi……………………..
*auk 2 Produki6 2 idak #roduki6
S#uum 2 0okla 2 kenal 2 en7er
2 berdarah
Ala *anu na#as 2 'idak ada 2 ada. jenis……
5ain(lain
*lood $*8% Suara janung S1 S8 S9 S: 2 'unggal 2 gallo#
2 murmur
Irama janung 2 regular 2 ireguler
0R' 2 ; 8 deik 2 < 8 deik
J3P 2 normal 2 meningka
03P 2 Ada 2 idak ada
Nilai:………………………………….
=dema 2 Ada 2 idak ada
5okasi
5ain(lain
*rain $*9% 'ingka kesadaran !ualiai6 :
!uaniai6 $&0S%:
=……………..3…………... M…………..
Reaksi #u#il
( kanan
( !iri
2 Ada. diameer:
2 idak ada
2 Ada. diameer>
2 idak ada
Re6lek 6isiologis 2 Ada 2 idak ada
Re6lek #aologis 2 brud4inski 2 7haddok
2 babinski 2 o#henhaim
2 +o66man rrommer
2 idak ada
Meningeal sign 2 ada 2 idak ada
5ain(lain
*ladder$*:% Urine Jumlah: warna:
!aeer 2 ada. hari ke: 2 idak ada
Jenis:…………………
!esulian *A! 2 "a 2 idak
5ain(lain
*owel $*?% Mukosa bibir 2 !ering 2 anemis 2 lembab
5idah 2 koor 2 bersih
!eadaan gigi 2 lengka# 2 gigi #alsu
5ain:………………..
N"eri elan 2 "a 2 idak
Abdomen 2 su#el 2 6la 2 disensi
Perisalik usus 2 normal 2 menurun 2 meningka
Nilai:
Mual 2 @a 2 idak
Munah 2 "a 2 idak
Jumlah-6rekuansi:
+aemaemesis 2 "a 2 idak
Jumlah-6rekuensi:
Melena 2 "a 2 idak
Jumlah-6rekuansi:
'er#asang N&' 2 "a 2 idak
Diare 2 "a 2 idak
Jumlah-6rekuensi:
!onsi#asi 2 "a 2 idak
Sejak:
As7ies 2 "a 2 idak
5ain(lain
*one $*A% 'urgor 2 baik 2 jelek
Perdarahan !uli 2 ada 2 idak ada
Jenis:
Ikerus 2 "a 2 idak ada
Akral 2 hanga 2 kering 2 merah
2 dingin 2 #u7a 2 basah
Pergerakan sendi 2 bebas 2 erbaas
Skala:
Brakur 2 ada 2 idak ada
Jenis:
5okasi:
5uka 2 ada 2 idak ada
Jenis:
5okasi:
5ain(lain
D. PEMERIKSAAN PENUNJANG
E. LAIN-LAIN
F. TERAPI
Suraba"a. .....................
$...............................%
ANALISA DATA
Nama :
Diagnosa medis :
No. RM :
DA'A ='I252&I MASA5A+
DS:
D2:
DS:
D2:
PRIORITAS MASALAH
1. ……………………………………………………………………………………………………
…...
8. ……………………………………………………………………………………………………
…...
9. ……………………………………………………………………………………………………
…...
INTERVENSI
Diagnosa !e#erawaan Iner)ensi Rasional
IMPLEMENTASI DAN EVALUASI
Diagnosa
ke#erawaan
Caku Im#lemenasi Para6 =)aluasi

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