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I.

PENGKAJIAN
Nama Pengkaji :
Tanggal Pengkajian :
Jam Pengkajian :

A. Biodata Pasien
Nama :
Jenis kelamin :
Pendidikan :
Pekerjaan :
Usia :
Status pernikahan :
No. RM :
Diagnosa Medis :

B. Biodata Penanggung Jawab


Nama :
Jenis Kelamin :
Pendidikan :
Pekerjaan :
Hubungan dengan klien :
Alamat :

C. Pengkajian Primer
1) Airway (Jalan Nafas)
Sumbatan
( ) benda asing
( ) darah
( ) bronkopasme
( ) sputum
( ) lendir
( ) bebas/tanpa sumbatan
Suara Nafas
( ) snoring
( ) gurgling
( ) stridor
Masalah keperawatan :

2) Breathing (pernafasan)
Sesak, dengan
( ) aktivitas
( ) tanpa aktivitas
( ) menggunakan otot tambahan
Frekuensi .......x/menit
Irama : ( ) teratur ( ) tidak teratur
Kedalaman : ( ) dalam ( ) dangkal
Batuk : ( ) produktif ( ) non produktif
Sputum : ( ) ada ( ) tidak ada
Warna : ...........
Konsistensi : ............
Bunyi nafas
( ) ronchi
( ) wheezing
( ) crackles
( ) ............
Masalah Keperawatan :

3) Circulation (sirkulasi)
Sirkulasi perifer
Nadi : ...........x/menit
Irama : ( ) teratur ( ) tidak teratur
Denyut : ( ) lemah ( ) kuat
TD : .........../.......... mmHg
Ekstremitas : ( ) hangat ( ) dingin
Warna kulit : ( ) cyanosis ( ) pucat ( ) kemerahan
Nyeri dada : ( ) ada ( ) tidak ada
Karakteristik nyeri dada
( ) menetap
( ) menyebar
( ) seperti ditusuk-tusuk
( ) seperti ditimpa benda berat
CRT : ( ) <2 detik ( ) >2 detik
Edema : ( ) iya ( ) tidak
Lokasi edema
( ) muka
( ) tangan atas
( ) tungkai
( ) anasarka
Eliminasi dan cairan :
BAK : ..........x/hari
Jumlah : ( ) sedikit ( ) banyak ( ) sedang
Warna : ( ) kuning jernih ( ) kuning kental ( ) putih
Rasa sakit : ( ) iya ( ) tidak
BAB : .............x/hari
Diare :
( ) iya
( ) tidak
( ) berdarah
( ) cair
( ) berlendir
Turgor : ( ) baik ( ) sedang ( ) buruk
Mukosa : ( ) lembab ( ) kering
Suhu : .......°C
Masalah Keperawatan :

4) Disbility
Tingkat Kesadaran :
( ) compos mentis
( ) apatis
( ) somnolen
( ) stupor
( ) soporo coma
( ) koma
Pupil
( ) isokor
( ) anisokor
( ) miosis
( ) midriasis
Reaksi terhadap cahaya
Kanan
( ) positif
( ) negatif
Kiri
( ) positif
( ) negatif
GCS : E V M
Terjadi
( ) kejang
( ) pelo
( ) kelumpuhan\kelemahan
( ) mulut mencong
( ) afasia
( ) disartria
( ) berlendir
Nilai kekuatan otot

Refleks :
Babinsky :
Patella :
Bisep/trisep :
Brudynsky :
Masdalah Keperawatan :

5) Eksposure

D. Pengkajian Sekunder
1) Keluhan utama

2) Alergi terhadap obat/makanan

3) Medikasi/pengobatan terakhir
4) Event of injury/penyebab injury

5) Pengalaman pembedahan

6) Riwayat penyakit sekarang

7) Riwayat penyakit dahulu

8) Pemeriksaan head to toe


No Area
Hasil Pemeriksaan
. Pemeriksaan
1 Kulit dan Kepala
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2 Mata
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3 Hidung
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4 Bibir dan Mulut


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5 Telinga
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6 Leher
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7 Dada
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8 Axilla
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9 Abdomen
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10 Genetalia dan
Anus ........................................................................................
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11 Ektremitas atas Luka : ( ) iya ( ) tidak


dan bawah Dalam : ( ) dalam ( ) t idak
Perdarahan : ( ) iya ( ) tidak
Deformitas : ( ) iya ( ) tidak
Kontraktur : ( ) iya ( ) tidak
Nyeri : ( ) iya ( ) tidak
Krepitasi : ( ) iya ( ) tidak
E. Pemeriksaan penunjang

F. Terapi medis