NamaMahasiswa :
NIM :
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Riwayat alergi :
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Riwayat pengobatan :
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Snoring Stridor/crowing
Gurgling Tidak ada
Wheezing Tanda Fraktur Cervikal (ada/tidak ada)
Lain-lain (………………………………………)
Laju Pernafasan
Dispnea Tachipneu Bradipneu
Orthponeu Apneu Lain-lain (………………)
RR : …..
Irama Pernafasan
Teratur Tak TeraturLain-lain (………………)
PengembanganParu
Simetris Asimetris Lain-lain (………………)
Flail Chest
Perkusi pernafasan
Sonor Hipersonor Pekak
Lain-lain (………………)
Oksigenasi
Akral dingin Pucat Sianosis
Lain-lain
(………………………...........................................................................................
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BLOOD
Perdarahan
Lokasi : …
Jumlah :…
Pulsasi
Kuat Lemah Tidak teraba
Laju nadi
Takikardia Bradikardia Normal
Ket : …. x/mnt
Tekanan darah
Hipotensi Hipertensi Tidak terukur
Normal
TD : … mmHg
Nyeri dada
Ada Tidak ada
Lokasi :…
Karakteristik : …
Jumlah :…
Perfusi
Akral dingin Pusing/nyeri kepala Kesemutan
Tremor Pucat Edema
Pengisian kapiler < 3 detik > 3 detik
Produksi Urine
AnuriaOliguria
Normal
Urine output : … CC/jam
BRAIN
Kesadaran
Compos mentis Samnolen Koma
Delirium Apatis
GCS
Eye .... Verbal ... Motorik …
Pinpoint
Lain-lain ...
Lain-lain : (............................................................................................................)
BLADDER
Lain-lain ...
BONE
Problem : ...
Regio : ...
Timing : ...
Kualitas/kuantitas : ...
Skala : ...
Deformitas Ada Tidak ada Lokasi...
Grade : ... %
Jika ada luka/vulnus, kaji :
Kedalaman : ...
Makan/minum : 0 1 2 3 4
Mandi : 0 1 2 3 4
Toileting : 0 1 2 3 4
Berpakaian : 0 1 2 3 4
Mobilisasi : 0 1 2 3 4
Berpindah : 0 1 2 3 4
Ambulasi : 0 1 2 3 4
Lain-lain : ....
Keterangan :
0 : Mandiri
1 : Alat bantu
2 : Dibantu orang lain
3 : Dibantu orang lain dan alat
4 : Tergantung total
Keracunan (intoksikasi)
Pengkajian Sekunder
Thorak
Ekstremitas
Integumen
Pemeriksaan Penunjang & Terapi Medis