A. PENGKAJIAN
Tanggal Masuk :.................................................
Tanggal Pengkajian : ……………………………….
I. Identitas Klien
Nama : ……………………………….
Umur : ……………………………….
Jenis Kelamin : ……………………………….
Alamat : .................................................
Diagnosa Medis :..................................................
No. RM : .................................................
II. Identitas Penanggung Jawab
Nama : .................................................
Umur : .................................................
Jenis Kelamin : .................................................
Alamat : .................................................
Hub. Dengan Klien : .................................................
a. PRIMARY SURVEY
CIRCULATION
Nadi : Teraba Tidak terbara
Nadi :......X/Menit, Irama nadi : Teratur Tidak teratur
Perdarahan : Ada Tidak ada, tempat perdarahan :.................................
Perfusi / CRT :......
Sianosis : Ya Tidak
Tekanan Darah : ..............mmHg
Suara Jantung :.............................
AIRWAY
Look ( Melihat obstruksi jalan nafas )
Obstruksi jalan nafas : Ada Tidak ada
Jika ada berupa :
Sekret Darah Benda asing Lidah jatuh ke belakang
Listen ( Mendengarkan suara jalan nafas )
Gurgling Snoring Crowing
Feel ( Meraba )
Hembusan udara : Hidung Mulut
Deviasi trakhea :....................................
BREATHING
Look (Lihat pergerakan dada)
Pengembangan dada : Simetris, tidak simetris
Sesak nafas Retraksi intercosta Cuping hidung Distensi vena leher
Jejas di dada Luka terbuka di dada
Listen ( Mendengarkan suara pernafasan )
Vesikuler Bronkhovesikuler Bronkhial Trakheal
Whezzing Ronchi Krekles Stridor
Feel ( Meraba )
Krepitasi Nyeri tekan
Perkusi : Sonor, hipersonor, dulness
DISABILITY
Kesadaran : Alert Verbal respon Pain respon Unresponsible
Kesadaran : Composmentis Apatis Somnolent Sopor Coma
GCS : ..............
Mata :............, Motorik :..........., Verbal :...........
Pupil : Isokor Miosis Pin Medriasis, reaksi terhadap cahaya :.......................
Papil edema : Ada Tidak ada
Lateralisasi : ya, tidak
EXPOSURE
Jejas : ada, tidak ada, tempat jejas :......................................................
Lesi : ada, tidak ada, tempat lesi :..........................................
Kelainan bentuk :....................................
Nyeri :............................
Folley cateter
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Gastric tube
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Heart monitoring dan oxymetri
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b. SECUNDERY SURVEY
Keadaan Umum
Tekanan Darah : .........................................
Nadi : .........................................
RR : .........................................
Suhu : .........................................
Anamnesa
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Keluhan
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Obat-obatan
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Makanan
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Penyakit penyerta
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Alergi
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Kejadian
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Tubes and finger in every orifice
Lubang hidung :..........................
Lubang telinga :..........................
Lubang anus :..............................
Lubang vagina :..............................
Pemeriksaan kulit kepala
Inspeksi :
Laserasi : ............................
Kontusio :............................
Luka termal :........................
Perdarahan :.........................
Palpasi :
Nyeri tekan :...............................
Fraktur :......................................
Wajah
Mata
Inspeksi :
Cornea :.................................
Pupil :...................................
Racon eyes:..........................
Hidung
Pembengkakan :.................................
Krepitasi / fraktur :............................
Zygoma
Pembengkakan :.................................
Krepitasi / fraktur :...........................
Telinga
Keutuhan membrantimpani :..............
Hemotimpanium :..............................
Tanda batle sign :................................
Rahang atas
Stabilitas rahang :........................
Krepitasi / fraktur :.........................
Pembengkakan :............................
Deformitas :..................................
Rahang bawah
Stabilitas rahang :........................
Krepitasi / fraktur :.......................
Pembengkakan :...........................
Deformitas :.................................
Vertebra servikalis / Leher
Inspeksi
Jejas :................
Deviasi trakhea....................
Pemakaian otot pernafasan tambahan :...........................
Palpasi
Nyeri tekan :...........................
Deformitas :............................
Pembengkakan :......................
Torak
Jejas : .................................
Luka terbuka : .................................
Nyeri tekan : .................................
Krepitasi : .................................
Paru-paru
Inspeksi :........................................
Palpasi :.........................................
Perkusi :..........................................
Auskultasi :.....................................
Jantung
Inspeksi :......................................
Palpasi :........................................
Perkusi :.........................................
Auskultasi :...................................
Abdomen
Inspeksi :............................................
Auskultasi :........................................
Perkusi :.............................................
Palpasi :..............................................
Pelvis
Kestabilan posisi :..............................
Jejas :..................................................
Nyeri tekan :........................................
Pembengkakan :.................................
Krepitasi / fraktur :............................
Deformitas :.........................................
Ekstremitas
Inspeksi :
Laserasi :.....................................
Perdarahan :...............................
Pembengkakan :............................
Deformitas :..................................
Palpasi :
Nyeri tekan :...............................
Krepitasi :...................................
Kekuatan otot :...............................
Punggung
Jejas :............................
Pembengkakan :.........................
Deformitas :...............................
Nyeri tekan :..............................
Fraktur :....................................
c. PEMERIKSAAN DIAGNOSTIK
Pemeriksaan Laboratorium
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Pemeriksaan EKG
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Pemeriksaan CTScan/MRI
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Pemeriksaan USG
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Pemeriksaan yang lain
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Therapy
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