PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN AVICENNA KENDARI

REKAM I. IDENTITAS
ASUHAN KEPERAWATAN NO RM
PASIEN
(KEPERAWATAN KRITIS)
Pendidikan : ....................................
PENGKAJIAN Nama : .......................................
Alamat : .....................................
Umur : ........... Thn/Bln/Hr *)
Nama Pengantar: ............................. J.Kelamin: Laki-Laki / Perempuan *) .....................................
Hub. Dgn Pasien: ............................ St. Perkawinan: Kawin/Belum*)
Tanggal MRS: ........./ ........./ 20....
Kiriman Dari : ............................. Suku/Bangsa: .................................
Jam : ...............
Agama : .................................
Tanggal Pengkajian: ....../ ........./ 20....
Pekerjaan : .................................
Jam : ...............

TB: ...................... CM, BB: ...................Kg Alat Bantu yang dipakai: ................................................................................
DIAGNOSIS MEDIS:

II. RIWAYAT KEPERAWATAN Keluhan utama Saat ini:............................................

Alasan Masuk RS: ...............................................
...............................................................................................
.........................................................................................
................................................................................................
.........................................................................................
...............................................................................................
......................................................................................... ....................................................................................................

Upaya yg telah dilakukan: .................................................................................................................................................

Riwayat Penyakit Yg pernah diderita:

Pernah menderita penyakit: .......................................................................Kapan: ................................................................

Pernah dioperasi: .......................................................................................Kapan: .................................................................

Pernah dirawat di RS Karena: ....................................................................Kapan: ...........................Lamanya: .....................

Alergi Obat: .................................................................... Alergi Makanan: .......................................................................

III. OBSERVASI DAN

3. Tanda Vital:
PEMERIKSAAN FISIK
Tensi : ............./ .............mmHg Suhu : ...............O C
1. Keadaan Umum: ........................................................
2. Kesadaran: Compos Mentis Apatis Dilirum Nadi : .....................X/Menit Pernapasan : ...............X/Menit
Somnolent Sopor Coma
4. Pernapasan (Airway & Breathing= B1) 5. Cardiovasculer (Blood=B2)
Sesak Napas: Ya Tidak Orthopnoe Denyut Nadi: Ada Tidak ada
Pernapasan : Ada Tidak ada ................................................................................................
Cyanosis: Bibir Kuku/Jari-jari Tidak Nyeri dada: Tidak Ya, Bila Ya Jelaskan:..................
Bentuk Dada: Simetris Tidak Simetris
Gerakan Pernapasan: Cuping Hidung See Saw ..............................................................................................
Retraksi Intercostal Retraksi Irama Nadi: Tertur Tidak teratur
Subkavikula Palpitasi : Tidak Ya
Pola Napas: Cepat dangkal / Dalam*) Perfusi : Hangat Kering Merah Pucat
Batuk : Berdahak Kering Darah Tidak Akral Dingin Basah
Suara Napas: Vesikuler Ronchi Kiri/Kanan*) CRT : <3 detik >3 detik
Rales Frition Rub JVP : <5 cm >5 cm
Wheezing Kiri/Kanan*) Bunyi Jantung: S1/S2 Murni /Abnormal S3 S4
Lainnya:............................... Murmur Gallop Thrill
Alat Bantu Napas: Canul Nasal Masker Biasa Edema: Anasarka Palpebra Extremitas atas
Masker rebrhiting/Non Rebrhiting*) Extremitas bawah
OT NT Tracheostomi Ventilator Aktivitas Derajat : I II III IV
Lainnya: ............................
Keluhan Lainnya: ................................................................
Keluhan Lainnya: ...............................................................
..............................................................................................
...........................................................................................
6. Persarafan (Brain=B3) 7. Perkemihan / Eliminasi Uri (Bledder=B4)
Kecurigaan fraktur servical: Tidak Ya Prod urine: ............ml; ..........x/hari; Oliguri/Anuri/Poliuri*)
Retensi urine Inkontinensia Urine
Jelaskan:............................................................................
GCS: E: ............ V: .............. M: .............. Total: ...........
Refleks Pupil: ( ) Isokhor Anisokhor Disuria: Tidak Ya, Bila Ya Jelaskan:.......................
Ukuran: ..........................mm
Refleks Patologis: Rangsang Meningeal: Kaku Kuduk ..............................................................................................
Kernig sign Budsinzki Neck Sign
Brudsinzkis Contralaterl Leg sign Babinsky(.....I.....) Warna Urine: ...............................................; Hematuri
Kejang: Klonik Tonik Fokal Umum
Palpasi: Ginjal: Teraba / Tidak Teraba*)
Grand Mall Petit Mall Tremor Twitching
Proses Pikir: Cemas Takut Gelisah Vesika Urinaria: Kosong Lunak Keras
Persepsi Sensori: Genitalia: Sirkum / Tdk Sirkum Priapismus
Penglihatan:................................................................
Hipospadia Epispadia Fimosis Kriptokismus
Penciuman:.................................................................
Blanitis Hernia Verikokel
Pendengaran:.............................................................
Pengecapan:..............................................................
Perabaan:...................................................................
Keluhan Lainnya: ...............................................................
Sakit Kepala : Tidak Ya, Bila Ya Jelaskan:..............

.............................................................................................. ...........................................................................................

Keluhan Lainnya: ...............................................................

...........................................................................................

8. Pencernaan /Eliminasi Alvi (Bowel=B5) 9. Muskuloskeletal/Integumen (Bone=B6)

Keluhan: Mual Kurang/Tidak ada nafsu makan
Keluhan Nyeri: Tidak Ya, Bila Ya Jelaskan:..........
Muntah: .........Kali (................................................)

Nyeri Abdomen: Tidak Ya, Bila Ya Jelaskan:.......... .............................................................................................

............................................................................................. Fraktur : Tidak Ya, Bila Ya Jelaskan:.......................

.
Bekas Luka Operasi: Tidak Ya; ............................... ..............................................................................................

Bising Usus: ...........X/menit; Peristaltik: ............................... Pergerakan Sendi: Bebas Terbatas;.............................

Perkusi: Tympani Hypertimpani Pekak Deformitas: : Tidak Ya Atropi Kontraktur
Palpasi: Hepar (Tidak Teraba/Teraba) Ukuran .................... Kekuatan Otot:
Limpa(Tidak Teraba/Teraba) Ukuran ....................
Massa (Tidak Teraba/Teraba) Ukuran ...................

Luka: : Tidak Ya, Bila Ya Jelaskan:.......................

BAB: .................X/Hari; Konsistensi: ...............................
Diare Konstipasi Faeces Berdarah Melena ..............................................................................................

Rectum:............................................................................... Kedaan Kulit: .......................................................................

Keluhan Lainnya: ............................................................... ..............................................................................................

Turgor : Baik Cukup Menurun/Jelek
........................................................................................... Keluhan Lainnya: ...............................................................

...........................................................................................
IV.TERAPI (Tulis Tanggal)
V. PEMERIKSAAN PENUNJANG (Tulis Tanggal)
(Pemeriksaan Laboratorium, Radiologi, EKG dan Pemeriksaan Penunjang Lainnya)