Sekolah Tinggi Ilmu Kesehatan

BINA USADA BALI

SK MENDIKNAS RI. NOMOR 122/D/O/201
TERAKREDITASI BAN PT. NOMOR 351/SK/BAN- PT/Akred/PT/IV/2015
Komplek Kampus MAPINDO Jl. Padang Luwih, Tegal Jaya Dalung- Badung
Telp. (0361) 433132, Fax. 419959 Email: binausada@yahoo.com Web: binausadabali. ac.id

PENGKAJIAN KEPERAWATAN INTENSIF

Tgl/Jam No. RM
Ruangan Diagnosa Medis

IDENTITAS
Nama /Inisial :
Jenis Kelamin :
Umur :
Status Perkawinan :
Agama :
Sumber Informasi :
Pendidikan :
Hubungan :
Pekerjaan :
Suku/Bangsa :
Alamat :

RIWAYAT SAKIT DAN KESEHATAN

Keluhan utama saat MRS
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Keluhan utama saat pengkajian
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Riwayat penyakit saat ini

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Riwayat alergi
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Riwayat pengobatan
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Riwayat penyakit sebelumnya dan riwayat penyakit keluarga

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BREATHING
Jalan Nafas : Paten Tidak Paten
Obstruksi : Lidah Cairan Benda Asing Tidak Ada
Muntahan Darah Oedema Tidak Ada
Suara Nafas : Snoring Gurgling Stidor 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 Stroke Lain...........
Suara Nafas : Vesikuler Stidor Wheezing Ronchi
Sesak Nafas : Ada Tidak Ada
Cuping hidung : Ada Tidak Ada
Retraksi otot bantu nafas : Ada Tidak Ada
Pernafasan : Pernafasan Dada Pernafasan Perut
Batuk : Ya Tidak Ada
Sputum : Ya, Warna:............... Konsistensi..............
Volume.............. Bau......................... Tidak Ada
RR :....................x/menit
Alat bantu nafas : OTT ETT Trakeostomi Ventilator
Keterangan :..........................
Oksigenasi : ..........lt/menit Nasal Kanul Simpel mask
Non RBT mask RBT mask Tidak Ada
Lain :

Masalah Keperawatan : ....................................................................................

BLOOD
Nadi : Teraba Tidak Teraba N :............x/menit
Tekanan darah: mmHg
Pucat : Ya Tidak
Sianosis : Ya Tidak
CRT : <2detik >2 detik
0
Akral : Hangat Dingin S : C
Pendarahan : Ya, lokasi :.................... Jumlah ................cc Tidak Ada
Turgor : Elastis Lambat
Diaphoresis : Ya Tidak
Riwayat kehilangan cairan berlebih : Diare Muntah Luka Bakar
IVFD : Ya Tidak, Jenis Cairan :...................................
Lain :

Masalah Keperawatan :......................................................................................

BRAIN
Kesadaran : Composmentis Delirum Somnolen Apatis
Koma
GCS : Eye....... Verbal....... Motorik........
Pupil : Isokor Unisokor Pinpoint Medriasis
Reflek Cahaya : Ada Tidak Ada
Reflek Fisiologis : Patela(+/-) Lain-lain.....................
Reflek Patologis : Babinzky (+/-) Kerning(+/-) lain-lain...............
Reflek pada bayi : reflek rooting(+/-) reflek moro (+/-)
(Khusus PICU/NICU) reflek sucking (+/-)
Bicara : lancar cepat lambat
Tidur Malam :..........jam Tidur siang:..........jam
Ansietas : Ada Tidak ada
Lain:

Masalah Keperawatan:.......................................................................................

BLADDER
Nyeri pinggang : Ada Tidak
BAK : Lancar Inkontinensia Anuri
Nyeri BAK : Ada Tidak Ada
Frekuensi BAK :..........Warna..........Darah : Ada Tidak Ada
Kateter : Ada Tidak Ada, Urine output :...............
Lain

Masalah Keperawatan:.......................................................................................

BOWEL
TB :..........cm BB : ..........Kg
Nafsu Makan : Baik Menurun
BAB : Teratu Tidak
FrekKeluhan : Mual Muntah Sulit Makan
Makan : Frekuensi..............x/hr jumlah............porsi
Minum : Frekuensi..............gls/hr jumlah............cc/hr
Perut Kembung : Ya Tidak
uensi BAB : ..............x/hr Konsistensi:.............. warna :.............
Darah(+/-) lendir ( +/-)
Lain :
Masalah Keperawatan :....................................................................................

BONE
Qualitas/Quantitas :
Nyeri : Ya Tidak
Problem : Skala :
Regio :
Timing :
Kekuatan otot :

Defoemitas : 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 :

Aktivitas dan latihan : 0 1 2 3 4 ket :

0 : Mandiri
Makan/Minum : 0 1 2 3
1 : Alat bantu
4
2 :Dibantu
Mandi : 0 1 2 3 4 orang lain
Toileting : 0 1 2 3 4 3 : Dibantu
Berpakaian : 0 1 2 3 4 orang lain
dan alat
Mobilisasi di tempat tempat tidur : 0 1 2 3 4
4 : Tergantung
Berpindah : 0 1 2 3 4
Total
Ambulasi : 0 1 2 3 4
Lain-lain :

Masalah Keperawatan :......................................................................................

HEAD TO TOE
(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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Abdomen dan Pinggang

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Pelvis dan Perineum
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Ekstremitas
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TEST DIAGNOSTIK DAN TERAPI MEDIS

Hasil Laboratorium (TGL) :
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Terapi Medis saat ini (TGL) :

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Masalah Keperawatan :....................................................................................

DIAGNOSA KEPERAWATAN

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