I. PENGKAJIAN
A. IDENTITAS KLIEN
Nama Klien : ...................................................................................................................
No. RM : ...................................................................................................................
Usia : ...................................................................................................................
Jenis Kelamin : ...................................................................................................................
Tgl. MRS : ...................................................................................................................
Tgl. Pengkajian : ...................................................................................................................
Alamat : ...................................................................................................................
Status Pernikahan : ...................................................................................................................
Agama : ...................................................................................................................
Suku : ...................................................................................................................
Pendidikan Terakhir : ...................................................................................................................
Pekerjaan : ...................................................................................................................
Diagnosa medis : ...................................................................................................................
Dokter yang merawat : ....................................................................................................................
B. KELUHAN UTAMA
Saat MRS : ....................................................................................................................................
.........................................................................................................................................................
Saat Pengkajian : ...........................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
C. RIWAYAT PENYAKIT
1. Riwayat Penyakit Sekarang
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
2
Keterangan :
: Laki-laki : Garis perkawinan
: Perempuan : Tinggal serumah
/ : Sudah meninggal : Garis keturunan
: Klien
4. Riwayat Sosial
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
D. KEADAAN UMUM
1. Kesadaran : ............................................................................................................
Scale Coma Glosgow : ............................................................................................................
3
2. Tanda Vital
a. Tekanan darah : .......................
b. Nadi : .......................
c. Pernapasan : .......................
d. Suhu : .......................
E. PEMERIKSAAN FISIK
Area
No. Hasil Pemeriksaan
Pemeriksaan
1 Kulit dan Kepala
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
2 Mata
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
3 Hidung
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
4 Bibir dan Mulut
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
5 Telinga
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
6 Leher
......................................................................................................................
4
.......................................................................................................................
......................................................................................................................
......................................................................................................................
7 Dada
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
8 Axilla
.......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
9 Abdomen
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
10 Genetalia dan
Anus ......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
11 Ektremitas atas
dan bawah ......................................................................................................................
......................................................................................................................
.......................................................................................................................
4. Pola Nutrisi
a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalah : .................................................................................................................................
5. Pola Eliminasi
a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalah : .................................................................................................................................
8. Pola Koping
a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalah : .................................................................................................................................
G. PEMERIKSAAN SARAF
Meningeal sign
Kaku kuduk : ( - / + )
Kernig :(- / + )
Brudzinski I : ( - / + )
Brudzinski II : ( - / + )
Nervus Cranialis
Nervus I, Olfaktorius :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Nervus III, Oculomotorius, Nervus IV, Trokclearis dan Nervus VI, Abdusen :
.........................................................................................................................................................
.........................................................................................................................................................
Nervus V, Trigeminus :
.........................................................................................................................................................
.........................................................................................................................................................
Nervus X, Vagus :
.........................................................................................................................................................
.........................................................................................................................................................
Reflek Fisiologis
Trisep :(- / + )
10
Bisep :(- / + )
Brakioradialis : ( - / + )
Patella :(- / + )
Acilles :(- / + )
Reflek Patologis
Babinski :(- / + )
Chaddok :(- / + )
Schaeffer :(- / + )
Oppenheim :(- / + )
Gordon :(- / + )
Gonda :(- / + )
11
Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
19
Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
20