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:
Ukuran: ..............│............mm
Refleks Patologis: Rangsang Meningeal: Kaku Kuduk ..............................................................................................
Kernig sign Budsinzki Neck Sign
Brudsinzki’s 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:..............
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Keluhan Lainnya: ...............................................................
Turgor : Baik Cukup Menurun/Jelek
........................................................................................... Keluhan Lainnya: ...............................................................
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IV. TERAPI (Tulis Tanggal)
V. PEMERIKSAAN PENUNJANG (Tulis Tanggal)
(Pemeriksaan Laboratorium, Radiologi, EKG dan Pemeriksaan Penunjang Lainnya)