PENGKAJIAN KEPERAWATAN INTENSIVE

Tgl/ Jam : No. RM :

Ruangan : Diagnosis Medis :
Nama/Inisial : Jenis Kelamin :
Umur : Status Perkawinan :
IDENTITAS

Agama : Sumber Informasi :

Pendidikan : Hubungan :
Pekerjaan :
Suku/ Bangsa :
Alamat :
RIWAYAT SAKIT DAN KESEHATAN

Keluhan utama saat MRS :......................................................................................

Keluhan utama saat pengkajian :......................................................................................

Riwayat penyakit saat ini :

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Riwayat Allergi :
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Riwayat Pengobatan :
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Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga:
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Jalan Nafas :  Paten  Tidak Paten
Obstruksi :  Lidah  Cairan  Benda Asing  Tidak Ada
 Muntahan  Darah  Oedema
Suara Nafas: Snoring Gurgling Stridor Tidak ada
Nafas :  Spontan  Tidak Spontan
Gerakan dinding dada:  Simetris  Asimetris
Irama Nafas :  Cepat  Dangkal  Normal
Pola Nafas :  Teratur  Tidak Teratur
Jenis :  Dispnoe  Kusmaul  Cyene Stoke  Lain… …
Suara Nafas :  Vesikuler  Stidor  Wheezing  Ronchi
Sesak Nafas :  Ada  Tidak Ada
Cuping hidung  Ada  Tidak Ada
Retraksi otot bantu nafas :  Ada  Tidak Ada
BREATHING

Pernafasan :  Pernafasan Dada  Pernafasan Perut

Batuk :  Ya  Tidak ada
Sputum:  Ya , Warna: ... ... ... Konsistensi: ... ... ... Volume: ... … Bau: … …
 Tidak
RR : ... ... x/mnt
Alat bantu nafas:  OTT  ETT  Trakeostomi
 Ventilator, Keterangan: ... ... ...
Oksigenasi : ... ... lt/mnt  Nasal kanul  Simpel mask  Non RBT mask  RBT
Mask  Tidak ada
Lain: … …

MasalahKeperawatan:
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 Nadi : Teraba Tidakteraba  N: … …x/mnt
TekananDarah : … … mmHg
Pucat :  Ya Tidak
Sianosis :  Ya Tidak
CRT : < 2 detik > 2 detik
Akral :  Hangat  Dingin  S: ... ...C
Pendarahan :  Ya, Lokasi: ... ... Jumlah ... ...cc  Tidak
Turgor : Elastis Lambat
BLOOD

Diaphoresis:  Ya Tidak
RiwayatKehilangancairanberlebihan: DiareMuntah Luka bakar
IVFD : Ya Tidak, Jeniscairan: … …
Lain: ... ...

MasalahKeperawatan:
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Kesadaran: Composmentis Delirium SomnolenApatisKoma
GCS : Eye ...  Verbal ... Motorik ...
Pupil : Isokor Unisokor PinpointMedriasis
RefleksCahaya:  Ada Tidak Ada
Refleksfisiologis: Patela (+/-) Lain-lain … …
Refleks patologis :  Babinzky (+/-)  Kernig (+/-)  Lain-lain ... ...
Refleks pada bayi:  Refleks Rooting (+/-)  Refleks Moro (+/-)
(Khusus PICU/NICU)  Refleks Sucking (+/-) 
BRAIN

Bicara :  Lancar  Cepat  Lambat

Tidur malam : … … jam Tidur siang : … … jam
Ansietas :  Ada  Tidak ada
Lain : … …

MasalahKeperawatan:
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Nyeri pinggang:  Ada  Tidak
BLADDER

BAK :  Lancar  Inkontinensia  Anuri

Nyeri BAK :  Ada  Tidak ada
Frekuensi BAK : … … Warna: ... ... Darah :  Ada  Tidak ada
Kateter :  Ada  Tidak ada, Urine output: ... ...
Lain: ... ...
 MasalahKeperawatan:
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TB : ... ...cm BB : ... ...kg
Nafsu makan :  Baik  Menurun
Keluhan :  Mual  Muntah  Sulit menelan
Makan : Frekuensi ... ...x/hr Jumlah : ... ... porsi
Minum : Frekuensi ... ... gls /hr Jumlah : ... ... cc/hr
Perut kembung :  Ya  Tidak
BOWEL

BAB :  Teratur  Tidak

Frekuensi BAB : ... ...x/hr Konsistensi: ... ... .. Warna: ... ... darah (+/-)/lendir(+/-)
Lain : ... ...
MasalahKeperawatan:
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 Nyeri :  Ada  Tidak
Problem : ... ... Qualitas/ Quantitas : ... ...
Regio : ... ... Skala : ... ...
Timing : ... ...
Kekuatan otot : ... ...
(Muskuloskletal & Integumen) BONE

Deformitas :  Ya Tidak Lokasi ... ...

Contusio :  Ya Tidak Lokasi ... ...
Abrasi :  Ya Tidak Lokasi ... ...
Penetrasi :  Ya Tidak Lokasi ... ...
Laserasi :  Ya Tidak Lokasi ... ...
Edema :  Ya Tidak Lokasi ... ...
Luka Bakar :  Ya Tidak Lokasi ... ...
Grade : ... ... %
Jika ada luka/ vulnus, kaji:
Luas Luka : ... ...
Warna dasar luka: ... ...
Kedalaman : ... ...

Keterangan:
Aktivitas dan latihan :0 1 2 3 4 0; Mandiri
1; Alatbantu
Makan/minum :0 1 2 3 4 2; Dibantu orang lain
3; Dibantu orang lain & alat
Mandi :0 1 2 3 4
4; Tergantung total
Toileting :0 1 2 3 4
Berpakaian :0 1 2 3 4
Mobilisasi di tempat tidur :  0 1 2 3 4
Berpindah : 0 1 2 3 4
Ambulasi : 0 1 2 3 4
 MasalahKeperawatan:
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(Fokus pemeriksaan pada daerah trauma/sesuai kasus non trauma)
Kepala dan wajah :
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Leher :
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Dada :
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HEAD TO TOE

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Abdomen dan Pinggang :
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Pelvis dan Perineum :
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Ekstremitas :
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Masalah Keperawatan:
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 Hasil laboratorium (TGL): … …
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TEST DIAGNOSTIK DAN TERAPI MEDIS

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Terapi medis saat ini (TGL): … …
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Masalah Keperawatan:
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