PENGKAJIAN ASUHAN KEPERAWATAN

Nama Mahasiswa : ……………………………………………………..

NIM : ……………………………………………………..
Kelompok : ……………………………………………………..

Identitas Klien:
Nama : ……………………………………………………..
Umur : ……………………………………………………..
Suku : ……………………………………………………..
Agama : ……………………………………………………..
Jenis Kelamin : ……………………………………………………..
Status Perkawinan : ……………………………………………………..
Pekerjaan : ……………………………………………………..
Pendidikan terakhir : ……………………………………………………..
Tanggal MRS : ……………………………………………………..
Alamat : ……………………………………………………..
Tanggal dan Jam pengkajian : ……………………………………………………..
Diagnosis medis : ……………………………………………………..
Hari dirawat : ……………………………………………………..
No. Rekam Medik : ……………………………………………………..
Keluhan Utama Saat Ini:

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Riwayat Penyakit Sekarang:

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Riwayat Penyakit Dahulu:

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Riwayat Penyakit Keluarga:

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Riwayat Pengobatan:
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Pemeriksaan Fisik
Penampilan Umum:
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Berat Badan= _____ kg; Tinggi Badan= _____ cm

Tanda Vital: TD =………… mmHg; Nadi =……. x/menit; Suhu =……..oC;

RR = ……... x/menit.

Komponen Pemeriksaan Fisik

Kulit, rambut, Kulit: ……………………………………………………...
kuku ……………………………………………………………..
Rambut: …………………………………………………..
Kuku: ……………………………………………………..
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Kepala dan leher Kepala: ……………………………………………….......
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Leher:
Kelenjar tiroid: …………………………………………....
JVP: ……………………………………………………….
Kaku kuduk: ……………………………………………...

Fungsi penglihatan:
Posisi bola mata: ………………………………………….
Gerakan bola mata: ……………………………………….
Konjungtiva: ……………………………………………...
Sklera: …………………………………………………….
Pupil: ……………………………………………………...
Keluhan nyeri: …………………………………………....
Pemakaian alat bantu penglihatan: ……………………….

Fungsi pendengaran:
Struktur luar telinga: ……………………………………..
Cairan dari telinga: ……………………………………….
Keluhan nyeri: ……………………………………………
Penggunaan alat bantu dengar: …………………………..

Mulut:
Mukosa bibir: …………………………………………….
Kebersihan mulut: ………………………………………..
Gigi: ……………………………………………………....
 Tenggorokan:
Penggunaan NGT: ………………………………………..
Kesulitan menelan: ……………………………………….
Deviasi trakea: ……………………………………………
Hidung:
Fungsi penciuman: ……………………………………….
Kondisi hidung: ………………………………………….
Cairan dari hidung: ………………………………………
Neurologis Tingkat kesadaran: ……………………………………….
GCS: E= , V= ,M=
Pengambilan keputusan: ………………………………….
Status mental: ……………………………………………
Kardiovaskular Bunyi jantung: ……………………………………………
Suara Jantung: …………………………………………….
Iktus kordis, PMI: ……………………………………......
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Capillary refill time: ……………………………………...
Edema: ……………………………………………………
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Palpitasi: ………………………………………………….
JVP: ………………………………………………………
Hepatojugular refleks: ……………………………………
MAP: ………………………………………………..........
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Suhu ekstremitas: ………………………………………....
Riwayat penyakit jantung dalam keluarga: ……………….
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Pernapasan Frekuensi nafas: …………………………………………..
Kedalaman: ……………………………………………….
Irama: ……………………………………………………..
Bunyi nafas: ………………………………………………
Batuk: ……………………………………………………..
Penggunaan otot bantu nafas: …………………………….
Suara nafas tambahan: …………………………………….
Adanya sputum: …………………………………………..
Riwanyat penyakit asma/bronchitis/emfisema: …………..
Riwayat penyakit paru dalam keluarga: ………………….
Lain-lain: ………………………………………………….
Gastrointestinal Bising usus: ……………………………………………….
Struktur abdomen: ………………………………………..
Perkusi abdomen: …………………………………………
Nyeri tekan pada abdomen: ……………………………...
Urin Kateter: ……………………………………………………
Kondisi sekitar alat kelamin: ……………………………..
Muskuloskletal Pembengkakan sendi: ……………………………………..
Skala kekuatan otot:
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Rentang gerak: ……………………………………………
Keseimbangan dan cara berjalan: ………………………...
Genggaman tangan/refleks: ………………………………
Status Neurologis
Kesadaran :
CM / Apatis / Somnolen / Sopor / Delirium / Subkoma dan Koma
GCS :E V M
Reflek pupil : Isokor / Anisokor

Meningeal sign
Kaku kuduk :( - / + )
Kernig :(- / + )
Brudzinski I :(- / + )
Brudzinski II : ( - / + )

Nervus Cranialis
Nervus I, Olfaktorius : mampu membedakan aroma / tidak mampu

Nervus II, Optikus:

Lapang pandang :

Nervus III, oculomotorius, Nervus IV, Trokclearis dan Nervus VI, Abdusen:
Membuka mata :( / ) SDE
Reflek pupil : Isokor / Anisokor / SDE
Ptosis :( / )/ SDE
Diplopia :( / )/ SDE
Gerakan bola mata : / SDE

Nervus V, Trigeminus
Kepekaan sensasi wajah, mata, lidah dan gigi :
Mampu membedakan rasa benda tajam dan tumpul / tidak mampu /
SDE
Reflek kornea (berkedip) :( / )/ SDE
Pergerakan rahang dan gigi : mampu membuka / tidak mampu / SDE
Nervus VII, Facialis
Mengangkat alis :( / )/ SDE
Mengerutkan dahi : mampu / tidak mampu / SDE
Senyum : simetris / asimetris / SDE
Bentuk Wajah : : simetris / asimetris / SDE
Menutup mata :( / )/ SDE

Nevus VIII, Vestibulokokhlearis

Pendengaran : mampu mendengar detik jam / tidak mampu / SDE
Vertigo: seimbang / tidak seimbang / SDE

Nervus IX, glosoparingeal dan Nervus X, Vagus

Menelan Saliva : mampu / tidak mampu / SDE
Reflek Muntah : ada / tidak ada / SDE

Nervus XI, Accessorius

Mengangkat bahu : mampu / tidak mampu / SDE
Menoleh : mampu / tidak mampu / SDE

Nervus XII, Hipoglosos

Deviasi lidah : ada, condong ke : kanan kiri / tidak ada / SDE
Afasia : bicara jelas / tidak jelas / tidak ada bicara / SDE

Reflek Fisiologis
Trisep :
Bisep :
Brakioradialis :
Patella :
Acilles :
Reflek patologis ( bila dijumpai pada kelumpuhan ekstremitas)
Babinski :
Chaddok :
Schaeffer :
Oppenheim :
Gordon :
Gonda :
PEMERIKSAAN LABORATORIUM
Nama: Tanggal: Jam:
Pemeriksaan Hasil Nilai Rujukan Satuan
HEMATOLOGI
Hemoglobin 14,0 – 18,0 g/dl
Eritrosit 4,0 – 10,5 ribu/µl
Leukosit 4,50 – 6,00 juta/µl
Hematokrit 42.00 – 52.00 vol%
Trombosit 150 – 450 ribu/µl
RDW-CV 11,5- 14,7 %
MCV, MCH, MCHC
MCV 80-97 Fl
MCH 27-32 Pg
MCHC 32-38 %
HITUNG JENIS
Basofil % 0,0-1,0 %
Eusinofil % 1,0-3,0 %
Gran % 50,0-70,0 %
Limfosit % 25,0-40,0 %
Monisit % 3,0-9,0 %
Basofil # <1 ribu/µl
Eusinofil # <3 ribu/µl
Gran # 2,50-7,00 ribu/µl
Limfosit # 1,25-4,0 ribu/µl
MID # 0,30-1.00 ribu/µl
PROTHROMBIN TIME
Hasil PT 9,9-13,5 detik
INR -
Control normal PT -
Hasil APTT 22,2-37,0 detik
Control normal APTT -
KIMIA
GULA DARAH
Gula darah sewaktu < 200 mg/dl
HATI
SGOT 0-46 U/l
SGPT 0-45 U/l
GINJAL
Ureum 10-50 mg/dl
Creatinin 0,7-14 mg/dl
ELEKTROLIT
Natrium 135-146 mmol/l
Kalium 3,4-5,4 mmol/l
Clorida 95-100 mmol/l
Terapi Medis yang diberikan:
Tgl Jenis Rute Dosis Indikasi Kontra indikasi
terapi terapi

Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RMK : ..............................................
No. Data (Symptom)
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ANALISA DATA
Penyebab (Etiologi)
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Masalah (Problem)
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 PRIORITAS MASALAH
Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
No. Masalah Keperawatan
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Paraf
(Nama Perawat)
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 RENCANA KEPERAWATAN
Tujuan Dan
No. Diagnosa Keperawatan
Kriteria Hasil
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 IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.
Waktu
Dx Tindakan
Tgl/jam
Kep
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Waktu Catatan Perkembangan
TT TT
Tgl/jam (SOAP)
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