MR. 3a PENGKAJIAN BEDAH NON TRAUMA
MR. 3a PENGKAJIAN BEDAH NON TRAUMA
NON TRAUMA/RI/2015
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MR.3A-II/B.NON TRAUMA/RI/2015
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MR.3A-III/B.NON TRAUMA/RI/2015
PENILAIAN NYERI
Nyeri : Tidak Ya: Lokasi: …………….……. Intensitas ……Skor : …… (Metode VAS/BPS/NIPS/FLACC)
TANDA-TANDA VITAL
KeadaanUmum: Baik Sedang Lemah Jelek, Gizi: Baik Kurang Buruk
GCS: E….... M….... V….…. Tindakan Resusitasi: Ya Tidak
BB : ………… Kg TB:……… cm
Tek. Darah: …………. mmHg, Nadi: …………. x/mnt
Respirasi: …….. x/mnt, SuhuAxila/Rektal: ………… OC/……………. OC
PEMERIKSAAN FISIS
Mata :Anemis: Tidak Ada,Ikterus: Tidak Ada,Pupil : anisokor Isokor, diameter ........../.......... mm,
UdemPalpebrae : Tidak Ada
THT : Tonsil:…………………, Faring: ………………………, Lidah: ………………………., Bibir:…………......……......................
Leher : JVP: ………………….., Pembesaran Kelenjar Limfe: Tidak Ada, ...........................................Kaku kuduk : Tidak Ada
Thoraks : Simetris Asimetris: ...................................................................................................................................
Cor : S1/S2 ……………………………. Reguler Ireguler, Murmur .......................................................................
Lain-lain :..............................................................................................................................................................................
Pulmo: Suara Nafas: ......................................, Ronchi: Tidak Ada ....................................................................
Wheezing : Tidak Ada, ............................................................................................................................
Abdomen : Distended : Tidak Ada, Meteorismus: Tidak Ada
Peristaltik : Normal Meningkat menurun Tidak ada, Asites: Tidak Ada
Nyeri Tekan: Tidak Ada, Lokasi: ............................................................................................................
Hepar : .........................................................., Lien : ..........................................................................................
Extremitas : Hangat Dingin Udem : Tidak Ada, ..................................................................
Lain-Lain: ..............................................................................................................................................................
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MR.3A-IV/B.NON TRAUMA/RI/2015
STATUS LOKALIS
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TERAPI
RENCANA KERJA
4/5
MR.3A-V/B.NON TRAUMA/RI/2015
HASIL PEMBEDAHAN
DIAGNOSA AKHIR
DISPOSISI
Hidup: Boleh pulang Jam Keluar: ……………wita Tanggal : ……………………………….
Kontrol polkinik: Tidak Ya,……………………….Tanggal: ……………..,………………
Dirawat diruang: Intensif/ ICU
5/5