FORMAT PENGKAJIAN KEPERAWATAN

Tgl/Jam MRS : …………………………………

Ruang : …………………………………
Nomor Register : …………………………………
Diagnosa Medis : …………………………………

A. Identitas Klien
Nama : …………………………………. Suami/Istri/Orang Tua :
Umur : …………………………………. Nama : ……………………..
Jenis Kelamin : …………………………………. Pekerjaan : ……………………..
Agama : …………………………………. Alamat : ……………………..
Suku/Bangsa : …………………………………. ……………………...
Bahasa : ………………………………….
Pendidikan : ………………………………….
Pekerjaan : ………………………………….
Status : ………………………………….
Alamat : ………………………………….
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B. Kasus Non Trauma

→ Subyektif
1. Keluhan Utama (PQRST)
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→ Obyektif
2. Tanda-tanda Vital
Tekanan Darah : ……………………. mmHg
Nadi : …………………….. x/menit, Kelaianan : …………………….
Respiratory Rate : …………………….. x/menit, Pola Napas : …………………….
Suhu : ……………………... 0C

C. Kasus Trauma
→ Subyektif
1. Keluhan Utama
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2. Mekanisme Trauma
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3. SAMPLE (symptom, allergy, medications, past illness, last meals, event)
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→ Obyektif
1. Airway
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2. Breathing
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3. Circulation
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4. Disability
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5. Exposure/Environtmental Control
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6. Full Set Of Vital Sign / Five Interventions
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7. Give Comfort
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8. Head To Toe Assesment
I. Kepala
i. Bentuk Kepala
‫ ۝‬Simetris ‫ ۝‬Asimetris ‫ ۝‬Dolikhosefalus
‫ ۝‬Brakhiosefalus ‫ ۝‬Hidrosefali ‫ ۝‬Mikrosefali
ii. Kulit Kepala
‫ ۝‬Luka ‫ ۝‬Benjolan ‫ ۝‬Tidak ada kelainan
iii. Rambut
‫ ۝‬Alopesia ‫ ۝‬Penyebaran Tidak Merata
‫ ۝‬Berbau ‫ ۝‬Kotor ‫ ۝‬tidak ada kelaian
iv. Wajah
‫ ۝‬Pucat ‫ ۝‬Kemerahan ‫ ۝‬Asimetris
‫ ۝‬Simetris ‫ ۝‬Sembab ‫ ۝‬Tidak ada kelainan
v. Ubun-ubun
‫ ۝‬Datar ‫ ۝‬Cekung ‫ ۝‬Cembung
‫ ۝‬terdapat benjolan ‫ ۝‬Tidak ada kelaianan

vi. Lain-lain
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II. Mata

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 i. Mata
‫ ۝‬Semetris ‫۝‬Asimetris
ii. Kelopak mata
‫ ۝‬Edema ‫ ۝‬Lesi ‫ ۝‬Peradangan
‫ ۝‬Benjolan ‫ ۝‬Ptosis ‫ ۝‬Ektropion
‫ ۝‬Entropion ‫ ۝‬Bulu mata rontok ‫ ۝‬Brill Hematom
iii. Konjungtiva
‫ ۝‬Anemis ‫ ۝‬Kemerahan ‫ ۝‬Tidak ada kelainan
iv. Sklera
‫ ۝‬Icterus ‫ ۝‬Kemerahan ‫ ۝‬Tidak ada kelainan
v. Pupil
Reflek cahaya : Langsung : ‫ ۝‬Positif ‫ ۝‬Negatif
Konsensual : ‫ ۝‬Positif ‫ ۝‬Negatif
Diameter : ‫ ۝‬Isokor ‫ ۝‬Anisokor
‫ ۝‬Miosis ‫ ۝‬Midriasis
vi. Kornea dan Iris
‫ ۝‬Terdapat lesi ‫ ۝‬Terdapat tanda peradangan
vii. Pergerakan bola mata
‫ ۝‬Keenam arah ‫ ۝‬Kelainan....................................................
viii. Lain-lain
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III. Hidung
i. Tulang hidung dan posisi septum nasi
‫ ۝‬Terdapat deviasi ‫ ۝‬Tidak ada kelainan
ii. Lubang hidung
‫ ۝‬Rinorea ‫ ۝‬Sumbatan
Mukosa : ‫ ۝‬Kering ‫ ۝‬Basah ‫ ۝‬Lembab
iii. Lain-lain
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IV. Telinga
i. Bentuk telinga
‫ ۝‬Simetris ‫ ۝‬Asimetris
ii. Lubang telinga
‫ ۝‬Ototea ‫ ۝‬Corpus alienum
iii. Prosesus mastoideus
‫ ۝‬Nteri tekan ‫ ۝‬Battle sign
iv. Lain-lain
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V. Mulut dan Faring

i. Bibir
‫ ۝‬Sianosis ‫ ۝‬Jejas
‫ ۝‬Kering ‫ ۝‬basah
ii. Gigi dan Gusi
‫ ۝‬Perdarahan ‫ ۝‬Gigi lepas
iii. Lidah

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 ‫ ۝‬Warna merah merata ‫ ۝‬Kotor
‫ ۝‬Luka ‫ ۝‬Bercak-bercak putih
iv. Rongga Mulut
‫ ۝‬Napas berbau ‫ ۝‬Peradangan ‫ ۝‬Luka
‫ ۝‬Sekret ‫ ۝‬Perubahan fonasi
v. Lain-lain
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VI. Leher
i. Trakea
‫ ۝‬Simetris ‫ ۝‬Deviasi ‫ ۝‬Pembesaran kel. tiroid
ii. Vena jugularis
‫ ۝‬Distensi ‫ ۝‬Tidak ada kelainan
iii. Lain-lain
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VII. Thorax / Paru
i. Bentuk
‫ ۝‬Normal chest ‫ ۝‬Pigeon chest ‫ ۝‬Funnel chest
‫ ۝‬Barrel chest ‫ ۝‬Kifosis ‫ ۝‬Skoliosis
ii. Pernapasan
‫ ۝‬Dyspnea ‫ ۝‬Retraksi intercosta
‫ ۝‬Retraksi supra sternal ‫ ۝‬Pernapasan cuping hidung
‫ ۝‬Sianosis ‫ ۝‬Pola napas .....................................
iii. Suara napas
‫ ۝‬Bronkial ‫ ۝‬Bronkovesikuler ‫ ۝‬Vesikuler
‫ ۝‬Ronchi ‫ ۝‬Whezing ‫ ۝‬Friction rubs
‫ ۝‬Stridor ‫ ۝‬Gurgling
iv. Perkusi
‫ ۝‬Sonor ‫ ۝‬Redup ‫ ۝‬Pekak
‫ ۝‬Hipersonor ‫ ۝‬Timpani
v. Palpasi (fremitus)
‫ ۝‬Kanan = Kiri ‫ ۝‬Kanan >> ‫ ۝‬Kiri >>
vi. Lain-lain
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VIII. Jantung
i. Inspeksi
‫ ۝‬Pulsasi ‫ ۝‬jejas
ii. Palpasi ictus cordis
‫ ۝‬Tidak teraba ‫ ۝‬Teraba di.................................diameter...........cm
iii. Suara jantung
‫ ۝‬BJ I & II tunggal ‫ ۝‬Bising/Mur-mur

iv. Perkusi
‫ ۝‬Batas jantung normal ‫ ۝‬Kardiomegali
v. Lain-lain
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 IX. Abdomen
i. Bentuk abdomen
‫ ۝‬Flat ‫ ۝‬Scapoid ‫ ۝‬Rounded
‫ ۝‬Protuberans ‫ ۝‬Spyder navy
ii. Peristaltik usus
‫ ۝‬Tidak ada ‫ ۝‬Ada, ...........................x/menit
iii. Benjolan/massa pada abdomen
‫ ۝‬ada ‫ ۝‬Tidak ada ‫ ۝‬Nyeri tekan
iv. Turgor kulit
‫ ۝‬Normal ‫ ۝‬Menurun
v. Perkusi
‫ ۝‬Sonor ‫ ۝‬Redup ‫ ۝‬Pekak
‫ ۝‬Timpani ‫ ۝‬Shifting dullness ‫ ۝‬Undulasi
vi. Lain-lain
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X. Ektremitas
i. Tulang
‫ ۝‬Simetris ‫ ۝‬Asimetris
ii. Range of Motion
‫ ۝‬Terbatas ‫ ۝‬Tidak terbatas
iii. Palpasi
‫ ۝‬Pitting edema ‫ ۝‬Non pitting edema
‫ ۝‬Krepitasi ‫ ۝‬Nyeri tekan
‫ ۝‬Hangat ‫ ۝‬Dingin
‫ ۝‬Lembab ‫ ۝‬Kering
iv. Jejas
‫ ۝‬Contusio ‫ ۝‬Abratio ‫ ۝‬Laserasi
v. Kekuatan otot
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vi. Tanda-tanda fraktur
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vii. Lain-lain
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XI. Pelvis dan Genetalia
‫ ۝‬Jejas ‫ ۝‬Benjolan ‫ ۝‬Luka
‫ ۝‬Pembengkakan ‫ ۝‬Perdarahan ‫ ۝‬Hematuria
‫ ۝‬Lain-lain ..................................................................................................

9. Inspect Posterior Surface

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D. Pemeriksaan Penunjang
1. Laboratorium
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2. Radiologi/USG/CT-Scan/MRI
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3. Elektrokardiografi
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Banyuwangi, ..............................., 20..

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 ANALISA DATA

NO DATA ETIOLOGI MASALAH

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 DAFTAR DIAGNOSA KEPERAWATAN
SESUAI PRIORITAS

NO DIAGNOSA KEPERAWATAN

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 TINDAKAN RESUSITASI

NO TGL/JAM TINDAKAN RESUSITASI KETERANGAN

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 IMPLEMENTASI

TGL/JAM Dx. NO TINDAKAN KEPERAWATAN PARAF

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