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 :.
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2. Riwayat Penyakit Sekarang :.




3. Riyawat Penyakit Dahulu :.

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III. RIWAYAT BIOLOGIS
1 Pola nutrisi
Sebelum sakit : .....................................................................................................
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Setelah sakit : .....................................................................................................
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2 Pola eliminasi
Sebelum sakit : .....................................................................................................
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Setelah sakit : .....................................................................................................
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3 Pola tidur dan istirahat
Sebelum sakit : .....................................................................................................
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Setelah sakit : .....................................................................................................
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4 Pola aktivitas dan latihan
Sebelum sakit : .....................................................................................................
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Setelah sakit : .....................................................................................................
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5 Pola bekerja
Sebelum sakit : .....................................................................................................
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Setelah sakit : .....................................................................................................
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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 perawatan :
c. Perubahan yang dirasa setelah sakit :...
Suasana hati :
Pertahanan koping
a. Pengambilan keputusan :....
b. Yang disukai tentang diri sendiri :
c. Yang ingin dirubah dari kehidupan :
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 cahaya) :..
Konjungtiva :..
Akomodasi :......
Lensa :..
Tanda Radang :..
Alat bantu :..
Riwayat Oprasi :..
SISTEM PENDENGARAN
Reaksi Alergi :..
Keluhan :..
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SISTEM PERNAPASAN
Pola Napas :.
Suara Napas :.
Sesak :
Batuk :.
Sputum :.
Nyeri :
Trauma dada :................
:.
:.
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SISTEM KARDIOVASKULER
HR : ........................................................................................................
Capilary Refilling : ........................................................................................................
JVP : ........................................................................................................
Suara Jantung : ........................................................................................................
Edema :.........................................................................................................
Nyeri :.........................................................................................................
Palpitasi :.........................................................................................................
BAAL :.........................................................................................................
Perubahan warna kulit :.........................................................................................................
Kuku :.........................................................................................................
Clabbing finger : .......................................................................................................
Akral Dingin :.........................................................................................................
SISTEM PENCERNAAN
NUTRISI
Intake : ........................................................................................................
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Output : ........................................................................................................
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Nafsu Makan :.........................................................................................................
Jenis Diet :.........................................................................................................
Mual muntah :.........................................................................................................
ELIMINASI
BAB :.........................................................................................................
BAK :.........................................................................................................
Keluhan/gangguan :.........................................................................................................
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Kateter :.........................................................................................................
SISTEM REPRODUKSI
GPA :...
Perdarahan :.
:.
:.
Keluhan :.
:
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SISTEM MUSKULOSKELETAL
Nyeri :.
Gangguan persendian :.
ROM :.
Pergerakan ekstremitas :.
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Kekuatan otot :.
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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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