ASUHAN KEPERAWATAN

I. PENGKAJIAN
Tanggal masuk :
Tanggal pengkajian :
A. Data Subjektif
1. Identitas Pasien
Nama :
Umur :
Alamat :
No Register :
Ruang :
Diagnosa Medis :

B. Pengkajian Sekunder
1. Keluhan utama
a. Saat MRS
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b. Saat Pengkajian
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2. Riwayat penyakit Dahulu

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 3. Riwayat penyakit Keluarga
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4. Riwayat Alergi
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II. PENGKAJIAN PRIMER

B1
(Breathing)

B2 (Blood)

B3 (Brain)

B4 (Blodder)

B5 (Bowel)
III. Data Objektif
A. Pemeriksaan fisik
1. Keadaan Umum : …………………………………………………………………
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2. Tanda-tanda vital
TD Nadi RR Suhu

3. Kepala
Bentuk

mata

hidung

telinga

mulut

leher

4. Dada
a. Jantung
Inspeksi
Palpasi
Perkusi
Auskultasi
b. Paru
Inspeksi
Palpasi
 Perkusi
Auskultasi

5. Abdomen
Inspeksi
Auskultasi
Perkusi
Palpasi

6. Ekstremitas
Ekstremitas Atas
Inspeksi
Auskultasi
Perkusi
Palpasi

Ekstremitas Bawah

Inspeksi
Auskultasi
Perkusi
Palpasi

7. Sistem Integumen
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8. Genetalia
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9. Eliminasi
BAB BAK
 Makan Minum

10. Pemeriksaan Penunjang

1) Laboratorium
Pemeriksaan Nilai Satuan
Nilai Nilai Nilai
Hb 13 – 16 %
Ht 40 – 54 %
Eritrosit 45 – 65 jt/ mmk
Leukosit 4 – 11 ribu/ mmk
Trombosit 150 - 400 ribu/mmk
Creatinin 0.6 - 1.3 mg/ dL
Albumin 3.4 – 5 mg/ dL
Gula Sewaktu 80 – 120 mg/ dL
Ureum 15 – 39 mg/ dL
Na 136 - 145 mmol/ L
K 3.5 - 5.1 mmol/ L
Cl 98 – 107 mmol/ L
Cholesterol 50 – 200 mg/ dL
Trigliserid 30 – 150 mg/ dL
Waktu 10 – 15 dtk
protrombin
PPT kontrol 12.8
Waktu 23.4 - 36.8 dtk
tromboplastin
pH 7,35–3,45
pCO2 35 – 45 mmHg
pO2 83 – 103 mmHg
HCO3 18 – 23 Mmol/L
AADO2 <100
Laktat 0,4 – 2
Base Excess

11. Pemeriksaan Penunjang

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12. Therapy

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