Riwayat Keperawatan
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Riwayat penyakit .....................................................................................................................................
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Riwayat Allergi .....................................................................................................................................
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Riwayat medikasi .....................................................................................................................................
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Keadaan umum : Baik Sedang Lemah
PENGKAJIAN PIMER
General Assessment : Pediatric Assesment Triangle
Appearance Mental status : Compos mentis Delirium Sopor Somnolen Koma
Muscle tone : Kuat Sedang lemah
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Body position : ...............................................................................................
PENGKAJIAN SEKUNDER
General observation
1. Keadaan umum pasien, catat posisi & postur tubuh
2. Pasien tampak menjaga/aktifitas yang melindungi diri
3. Masalah yang tampak terlihat
4. Tingkat stress secara umum
5. Perilaku pasien, tampak tenang, agitasi, letargi, kooperatif, gelisah
6. Pasien dapat melakukan ambulasi, tampak kuat/tegap dalam posisi kuat
7. Pasien dapat melakukan komunikasi verbal, berbicara dengan jelas, konsisten, kebingungan,
cadel, aphasic
8. Pasien tampak bau khas sesuatu, urin, keton, etanol, zat kimia
9. Tanda luka baru ataupun lama akibat injury
PEMERIKSAAN PENUNJANG
Jenis Pemeriksaan
Jam Hasil
Lab/Foto/ECG/lain lain
Pemberian Terapi
Jam Tindakan/ medikasi Keterangan
PERAWATAN INTENSIF
JAM Tensi RR HR SUHU º CVP SPO2 Input Output Medikasi
C (cc) (cc) Obat
TINDAKAN KEPERAWATAN
Waktu Analisa Data Kriteria Hasil Tindakan Evaluasi
Masalah Tujuan :................................... SOAPIE
Kep : .................................................. ..................................................
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........................................................... Kriteria Hasil :
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