FORMAT PENGKAJIAN LUKA &

ASUHAN KEPERAWATAN PADA LUKA

Nama Pasien : ....................................................... Usia (Jenis Kelamin) : ..................................... (L/P)

Diagnosa Penyakit : ...................................................... Jenis Luka : .............................................

Riwayat Penyakit : .............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

Riwayat Luka : .............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

Terapi / Obat : .............................................................................................................................................

Keluhan saat ini : .............................................................................................................................................

Gambar Luka (tanggal .................)

Lokasi : ............................................................................

Tipe Luka : ............................................................................

Tipe Penyembuhan : ............................................................................

Tgl ..................... Tgl .......................... Tgl ...........................

Stadium Luka

(1-unstage)

Ukuran Luka

(PxLxD/T)

Goa/Undermining

(di jam a-b, x cm, di jam c, y cm)

Odour / Bau

Exudate/Cairan luka

(tipe, jumlah)

Warna Dasar Luka

(x%red, y%yellow, z%black)

Dasar Luka/Wound Base

(menyatu dg dasar luka/tdk)

Tepi Luka

(tebal, tipis, halus, edema)

Kulit sekitar luka

(iritasi, maserasi, edema)

Tanda Infeksi

(ada/tdk, lokal/sistemik, kultur?)

Nyeri

(grade 1 - 10)

Pemeriksaan Fisik dan Penunjang

Tensi : ............................ mmHg; Suhu : .............. C; Nadi : ................ Kali/mnt; Respirasi : ................... x/mnt

Penunjang : GDS : ...................... Gr%; Kultur : ...................................................; Albumin Total : ...................... Gr%

Masalah Integritas Kulit

(nekrotik, infeksi, dll)

Tujuan Perawatan
1

4
Tindakan Perawatan
1

Evaluasi Perawatan

Petugas

Tanda tangan