LAPORAN ANALISA SINTESA

Nama Mahasiswa : ................................................... Ruangan : ...................

NIM : ...................................................

1. IDENTITAS PASIEN
Nama : .....................................................................................
Umur : .....................................................................................
Jenis Kelamin : .....................................................................................
Status Perkawinan : .....................................................................................
Agama : .....................................................................................
Suku Bangsa : .....................................................................................
Pekerjaan : .....................................................................................
Tanggal Masuk : .....................................................................................
Tanggal Pengkajian : .....................................................................................
Diagnosa Medis : .....................................................................................

2. RIWAYAT KESEHATAN
Keluhan utama :
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Riwayat keluhan utama :
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Riwayat kesehatan dahulu :
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PROFESI NERS UNG ANGK. XV

3. PENGKAJIAN
Pengkajian Segera (Quick Assesment)
a. Airway :
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Masalah keperawatan : .................................................................................
b. Breathing :
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Masalah keperawatan : .................................................................................
c. Circulation :
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Masalah keperawatan : .................................................................................
d. Disability :
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Masalah keperawatan : .................................................................................
e. Exposure :
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Masalah keperawatan : .................................................................................

Pengkajian Lengkap (Comprehensive Assesment)

a. B1 – Breathing
Inspeksi :
Bentuk dada: .................................................................................................
Pola nafas : .................................................................................................

PROFESI NERS UNG ANGK. XV

 Frekuensi : .................................................................................................
Otot bantu pernafasan: .................................................................................
Cuping hidung : .................................................................................
Alat bantu nafas : .................................................................................
Palpasi :
Nyeri tekan : .....................................................................................
Vocal premitus : .....................................................................................
Perkusi :
Hasil perkusi : ...............................................................................................
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Auskultasi :
Suara nafas : .................................................................................................
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Keluhan : .........................................................................................................
Masalah keperawatan B1 : ...........................................................................
b. B2 – Blood
Inspeksi :
CRT : .................................................................................................
Sianosis : .................................................................................................
Konjungtiva : ...............................................................................................
Irama jantung : .............................................................................................
Palpasi :
Akral : .....................................................................................
Frekuensi nadi : .....................................................................................
Tekanan darah : .....................................................................................

Keluhan : .........................................................................................................
Masalah keperawatan B2 : ...........................................................................

c. B3 – Brain
Kesadaran : .................................................................................................
GCS : E ..... V ..... M ..... = .......

PROFESI NERS UNG ANGK. XV

 Pupil : .................................................................................................
Nyeri kepala : .................................................................................................
Pusing : .................................................................................................
Pengkajian nervus :
Nervus I : .................................................................................................
Nervus II : .................................................................................................
Nervus III : .................................................................................................
Nervus IV : .................................................................................................
Nervus V : .................................................................................................
Nervus VI : .................................................................................................
Nervus VII : .................................................................................................
Nervus VIII: .................................................................................................
Nervus IX : .................................................................................................
Nervus X : .................................................................................................
Nervus XI : .................................................................................................
Nervus XII : .................................................................................................

Keluhan : .........................................................................................................
Masalah keperawatan B3 : ...........................................................................

d. B4 – Bladder
Keluhan : Kencing menetes Inkontinensia Hematuria
Retensi urine Oliguria
Poliuria Disuria
Kandung kemih : .....................................................................................
Nyeri tekan : .....................................................................................
Alat bantu berkemih : .....................................................................................
Produksi urine : .....................................................................................
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Keluhan : .........................................................................................................
Masalah keperawatan B4 : ...........................................................................

PROFESI NERS UNG ANGK. XV

e. B5 – Bowel
TB / BB : .................................................................................................
Mukosa bibir : .................................................................................................
Abdomen :
Inspeksi : .................................................................................................
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Auskultasi : .................................................................................................
Perkusi : .................................................................................................
Palpasi : .................................................................................................
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Frekuensi makan : .....................................................................................
Sulit menelan : .....................................................................................
NGT / OGT : .....................................................................................
BAB :
Frekuensi BAB : .....................................................................................
Konsistensi : .....................................................................................

Keluhan : .........................................................................................................
Masalah keperawatan B5 : ...........................................................................

f. B6 – Bone
Integritas kulit : .....................................................................................
Turgor kulit : .....................................................................................
Warna kulit : .....................................................................................
Pergerakan sendi : .....................................................................................
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Kekuatan otot : .....................................................................................
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Udema ekstremitas : .....................................................................................

Keluhan : .........................................................................................................
Masalah keperawatan B5 : ...........................................................................

PROFESI NERS UNG ANGK. XV

 Pengkajian Berkelanjutan (Ongoing Assesment)
Monitoring setiap hari , setiap jam .

4. PEMERIKSAAN PENUNJANG

5. TERAPI OBAT

PROFESI NERS UNG ANGK. XV