JURUSAN KEPERAWATAN P

FAKULTAS KESEHATAN A
UNIVERSITAS TRIBHUWANA TUNGGADEWI G
E
PENGKAJIAN DASAR KEPERAWATAN NON TRAUMA
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Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :

1. Identitas Klien
Nama : .......................................... No. RM : ........................................
Usia : ............. tahun Tgl. Masuk : ........................................
Jenis kelamin : .......................................... Tgl. Pengkajian : ........................................
Alamat : .......................................... Sumber informasi : ........................................
Status pernikahan : .......................................... Agama : ........................................
Suku : .......................................... Pendidikan : ........................................
Pekerjaan : .......................................... Dx.Medis : .......................................

2. Status kesehatan Saat Ini

1. Keluhan utama MRS : ...............................................................................................................
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2. Riwayat kesehatan sebelumnya : .................................................................................................
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3. Data Obyektif P
A
Airway G
E
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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 : .............................................................................................................................. P
A
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E
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: P
A
Jantung G
E
- Inspeksi:.................................................................................................................................
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- Palpasi: ..................................................................................................................................
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- Perkusi: ..................................................................................................................................
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- Auskultasi:..............................................................................................................................
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- 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 P
A
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G
E
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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 P
A
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G
E
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5. Terapi
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