PENGKAJIAN KEPERAWATAN INTENSIVETgl/ Jam:

No. RM:

Ruangan:

Diagnosis Medis:

IDENTITASNama/Inisial:

Jenis Kelamin :

Umur:

Status Perkawinan :

Agama:

Sumber Informasi :

Pendidikan :

Hubungan :

Pekerjaan :

Suku/ Bangsa :

Alamat :

RIWAYAT SAKIT DAN KESEHATANKeluhan utama saat MRS:......................................................................................Keluhan utama saat pengkajian:......................................................................................Riwayat penyakit saat ini:

..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Riwayat Allergi:

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Riwayat Pengobatan:

...................................................................................................................................................... ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Riwayat penyakit sebelumnya dan Riwayat penyakit keluarga:

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

BREATHINGJalan Nafas: ( Paten ( Tidak Paten

Obstruksi: ( Lidah ( Cairan ( Benda Asing ( Tidak Ada

( Muntahan( Darah( Oedema

Suara Nafas: (Snoring (Gurgling (Stridor (Tidak ada

Nafas:( Spontan

( Tidak Spontan

Gerakan dinding dada: ( Simetris ( Asimetris

Irama Nafas : ( Cepat ( Dangkal ( Normal

Pola Nafas : ( Teratur ( Tidak Teratur

Jenis: ( Dispnoe ( Kusmaul ( Cyene Stoke ( Lain

Suara Nafas: ( Vesikuler ( Stidor ( Wheezing ( Ronchi

Sesak Nafas : ( Ada ( Tidak Ada

Cuping hidung ( Ada( Tidak Ada

Retraksi otot bantu nafas : ( Ada ( Tidak Ada

Pernafasan : ( Pernafasan Dada ( Pernafasan Perut

Batuk: ( Ya ( Tidak ada

Sputum:( Ya , Warna: ... ... ... Konsistensi: ... ... ... Volume: ... Bau:

( Tidak

RR : ... ... x/mnt

Alat bantu nafas: ( OTT ( ETT ( Trakeostomi

( Ventilator, Keterangan: ... ... ...

Oksigenasi : ... ... lt/mnt ( Nasal kanul ( Simpel mask ( Non RBT mask ( RBT Mask ( Tidak ada

Lain:

MasalahKeperawatan: ...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

BLOODNadi: (Teraba(Tidakteraba( N: x/mnt

TekananDarah : mmHg

Pucat: ( Ya (Tidak

Sianosis: ( Ya (Tidak

CRT :(< 2 detik (> 2 detik

Akral : ( Hangat ( Dingin ( S: ... ...C

Pendarahan: ( Ya, Lokasi: ... ... Jumlah ... ...cc ( Tidak

Turgor:(Elastis(Lambat

Diaphoresis:( Ya (Tidak

RiwayatKehilangancairanberlebihan: (Diare(Muntah( Luka bakar

IVFD :( Ya (Tidak, Jeniscairan:

Lain: ... ...

MasalahKeperawatan: ...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

BRAINKesadaran: (Composmentis( Delirium (Somnolen(Apatis(Koma

GCS: (Eye ... ( Verbal ...(Motorik ...

Pupil: (Isokor(Unisokor(Pinpoint(Medriasis

RefleksCahaya:( Ada (Tidak Ada

Refleksfisiologis: (Patela (+/-) (Lain-lain

Refleks patologis: ( Babinzky (+/-) ( Kernig (+/-) ( Lain-lain ... ...

Refleks pada bayi: ( Refleks Rooting (+/-) ( Refleks Moro (+/-)

(Khusus PICU/NICU)( Refleks Sucking (+/-) (Bicara : ( Lancar ( Cepat ( Lambat

Tidur malam: jam Tidur siang: jam

Ansietas: ( Ada ( Tidak ada

Lain:

MasalahKeperawatan: ...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

BLADDERNyeri pinggang: ( Ada ( Tidak

BAK : ( Lancar ( Inkontinensia ( Anuri

Nyeri BAK : ( Ada ( Tidak ada

Frekuensi BAK : Warna: ... ... Darah : ( Ada ( Tidak ada

Kateter : ( Ada ( Tidak ada, Urine output: ... ...

Lain: ... ...

MasalahKeperawatan: ...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

BOWELTB : ... ...cm BB : ... ...kg

Nafsu makan : ( Baik ( Menurun

Keluhan : ( Mual ( Muntah ( Sulit menelan

Makan : Frekuensi ... ...x/hr Jumlah : ... ... porsi

Minum : Frekuensi ... ... gls /hr Jumlah : ... ... cc/hr

Perut kembung : ( Ya ( Tidak

BAB : ( Teratur ( Tidak

Frekuensi BAB : ... ...x/hr Konsistensi: ... ... .. Warna: ... ... darah (+/-)/lendir(+/-)

Lain : ... ...

MasalahKeperawatan: ...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

BONE

(Muskuloskletal & Integumen)Nyeri : ( Ada ( Tidak

Problem : ... ...Qualitas/ Quantitas: ... ...

Regio : ... ...Skala

: ... ...

Timing: ... ...

Kekuatan otot : ... ...

Deformitas : ( Ya (Tidak(Lokasi ... ...

Contusio: ( Ya (Tidak(Lokasi ... ...

Abrasi: ( Ya (Tidak(Lokasi ... ...

Penetrasi:( Ya (Tidak(Lokasi ... ...

Laserasi: ( Ya (Tidak(Lokasi ... ...

Edema: ( Ya (Tidak(Lokasi ... ...

Luka Bakar: ( Ya (Tidak(Lokasi ... ...

Grade : ... ... %

Jika ada luka/ vulnus, kaji:

Luas Luka: ... ...

Warna dasar luka: ... ...

Kedalaman : ... ...

Aktivitas dan latihan: ( 0 ( 1 ( 2 ( 3 ( 4

Makan/minum: ( 0 ( 1 ( 2 ( 3 ( 4

Mandi: ( 0 ( 1 ( 2 ( 3 ( 4

Toileting: ( 0 ( 1 ( 2 ( 3 ( 4

Berpakaian : ( 0 ( 1 ( 2 ( 3 ( 4

Mobilisasi di tempat tidur: ( 0 ( 1 ( 2 ( 3 ( 4

Berpindah:( 0 ( 1 ( 2 ( 3 ( 4Ambulasi:( 0 ( 1 ( 2 ( 3 ( 4Lain-lain : ... ...

MasalahKeperawatan: ...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

HEAD TO TOE(Fokus pemeriksaan pada daerah trauma/sesuai kasus non trauma)Kepala dan wajah:

...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................Leher:

...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................Dada:

...................................................................................................................................................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................Abdomen dan Pinggang:

...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................Pelvis dan Perineum:

...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................Ekstremitas:

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

Masalah Keperawatan:...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

TEST DIAGNOSTIK DAN TERAPI MEDISHasil laboratorium (TGL):

...................................................................................................................................................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ...................................................................................................................................................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................Terapi medis saat ini (TGL):

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

Masalah Keperawatan: ...................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................

Keterangan:

0;Mandiri

1;Alatbantu

2;Dibantu orang lain

3;Dibantu orang lain & alat

4;Tergantung total