format pengkajian keperawatan gadar
TRANSCRIPT
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PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN KRITIS
STIKES HANG TUAH SURABAYA
Nama mahasiswa : ………………………………………………………………………………….....NIM : ………………………………………………………………………………….....Ruangan : ………………………………………………………………………………….....Pengkajian diambil : ………………………………………………………………………………….....Diagnosa medis : ………………………………………………………………………………….....
A. IDENTITAS PASIENNama : ………………………………………………………………………………….....Umur : ………………………………………………………………………………….....Jenis kelamin : .................................................................................................................................Suku : .................................................................................................................................Agama : .................................................................................................................................Pendidikan : .................................................................................................................................Alamat : .................................................................................................................................
B. RIWAYAT KEPERAWATANKeluhan utama ......................................................................................................................................Riwayat penyakit sekarang (RPS)............................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Riwayat penyakit dahulu (RPD)............................................................................................................................................................... ..............................................................................................................................................................................................................................................................................................................................Riwayat kesehatan keluarga.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Genogram
C. PENGKAJIAN PERSISTEMKeadaan umum............................................................................................................................................................... ..............................................................................................................................................................................................................................................................................................................................Tanda-tanda vitalBP……………………………. mmHg
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HR……………………………. x/mnt, irama ………………… Pulsasi…………………RR……………………………. x/mnt, irama ………………….t……………………………….°C
Breath (B1) Pergerakan dada O Simetris O AsimetrisPemakaian otot bantu napas
O ada, Jenis : ……………O Tidak ada
Suara napas O Vesikuler O rhonkiO wheezingLokasi……………………..
Batuk O Produktif O tidak produktifSputum O Coklat O kental O encer
O berdarahAlat Bantu napas O Tidak ada O ada, jenis……Lain-lain
Blood (B2) Suara jantung S1 S2 S3 S4 O Tunggal O gallopO murmur
Irama jantung O regular O iregulerCRT O ≤ 2 detik O > 2 detikJVP O normal O meningkatCVP O Ada O tidak ada
Nilai:………………………………….Edema O Ada O tidak ada
LokasiLain-lain
Brain (B3) Tingkat kesadaran Kualitatif :Kuantitatif (GCS):E…………….,V………….., M…………..
Reaksi pupil- kanan
- Kiri
O Ada, diameter:O tidak adaO Ada, diameter;O tidak ada
Reflek fisiologis O Ada O tidak adaReflek patologis O brudzinski O chaddok
O babinski O ophenhaimO Hoffman trrommerO tidak ada
Meningeal sign O ada O tidak adaLain-lain
Bladder(B4) Urine Jumlah: warna:Kateter O ada, hari ke: O tidak ada
Jenis:…………………Kesulitan BAK O ya O tidakLain-lain
Bowel (B5) Mukosa bibir O Kering O anemis O lembabLidah O kotor O bersihKeadaan gigi O lengkap O gigi palsu
Lain:………………..Nyeri telan O ya O tidakAbdomen O supel O flat O distensiPeristaltik usus O normal O menurun O meningkat
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Nilai:Mual O Ya O tidakMuntah O ya O tidak
Jumlah/frekuansi:Haematemesis O ya O tidak
Jumlah/frekuensi:Melena O ya O tidak
Jumlah/frekuansi:Terpasang NGT O ya O tidakDiare O ya O tidak
Jumlah/frekuensi:Konstipasi O ya O tidak
Sejak:Ascites O ya O tidakLain-lain
Bone (B6) Turgor O baik O jelekPerdarahan Kulit O ada O tidak ada
Jenis:Ikterus O ya O tidak adaAkral O hangat O kering O merah
O dingin O pucat O basahPergerakan sendi O bebas O terbatas
Skala:
Fraktur O ada O tidak adaJenis:Lokasi:
Luka O ada O tidak adaJenis:Lokasi:
Lain-lain
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D. PEMERIKSAAN PENUNJANG
E. LAIN-LAIN
F. TERAPI
Surabaya, .....................
(...............................)
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ANALISA DATA
Nama :Diagnosa medis :No. RM :
DATA ETIOLOGI MASALAH
DS:
DO:
DS:
DO:
PRIORITAS MASALAH1. ………………………………………………………………………………………………………...2. ………………………………………………………………………………………………………...3. ………………………………………………………………………………………………………...
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INTERVENSI
Diagnosa Keperawatan Intervensi Rasional
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IMPLEMENTASI DAN EVALUASI
Diagnosa keperawatan
Waktu Implementasi Paraf Evaluasi
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