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FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAHTanggal MRSTanggal pengkajian Jam pengkajian Hari rawat::::Jam MasukNo.RM Diagnosa Masuk :::

IDENTITAS 1. Nama pasien :2. Umur : 3. Suku / Bangsa : 4. Agama : 5. Pendidikan : 6. Pekerjaan : 7. Alamat :

KELUHAN UTAMA 1. Keluhan utama : .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT SEKARANG 1. Riwayat penyakit sekarang : .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT DAHULU 1. Pernah dirawat : ya |_| tidak |_| kapan : .................... diagnosa :.......................2. Riwayat penyakit mennular ya |_|tidak |_|Jenis : ............................................Riwayat kontrol : ...........................................................................................................................Riwayat penggunaan obat : ...........................................................................................................3. Riwayat elergi : |_| Obat|_| Ya |_| Tidak Jenis :..........................................................|_| Makanan |_| Ya |_| Tidak Jenis : .........................................................|_| Lain-lain |_| Ya |_| Tidak Jenis : .........................................................4. Riwayat Operasi : Ya |_|Tidak |_| Kapan : ............................. .................................................................................... Jenis Operasi : ..................................................................................................................5. Lain-lain : .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................

RIWAYAT PENYAKIT KELUARGA |_| Ya |_| Tidak Jenis : ................................................................................................................. Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATAN Perilaku sebelum sakit yang mempengaruhi kesehatan :|_| Alkohol Ya |_|Tidak |_|Keterangan : .....................................................|_| Merokok Ya |_|Tidak |_|Ketearangan : ...................................................|_| Obat Ya |_|Tidak |_|Keterangan : ....................................................|_| Olahraga ya |_|Tidak |_|Keterangan : .....................................................

OBSERVASI DAN PEMERIKSAAN FISIK 1. Tanda-Tanda Vital S : N : T : RR : Kesadaran : |_| composmentis |_| Apatis |_| Samnolen |_| Sopor |_| Koma 2. Sistem pernafasan a. RR : ................................................................b. Keluhan : |_| Sesak |_|Nyeri Waktu Nafas |_| OrthopneaBatuk |_| Produkstif |_|Tidak produktifSekret : ...........................................konsistensi : ..................................Warna : ...........................................Bau : ...........................................c. Penggunaan otot bantu nafas : .......................................................................................................................................................................................................................................................................................................d. PCH : Ya |_|Tidak |_|e. Irama nafas |_| teratur |_| tidak teratur f. Friction Rub : ...........................................................................................................................g. Pola nafas |_| Dispnea |_| Kusmaul |_| Cheyne Stokes |_| Biot h. Suara Nafas |_| Vasikuler |_| Bronko Vesikuler |_| Tracheal |_| Bronkhial |_| Ronki |_|Wheezing |_| Crackles i. Alat bantu nafas |_| ya |_| tidak Jenis ....................................................................Flow ....................................lpm j. Penggunaan WSD : ;jenis : Jumlah cairan : Undulasi : Tekanan :k. Obstruksi:Tidak |_|Sebagian|_|Total |_|l. Benda Asing: Tidak |_|Padat|_|Cair |_|Berupa: m Penggunaan Ventilator: Ya |_|Tidak |_|

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n Tracheostomy : Ya |_|Tidak |_|........................................................................................................................................................................................................................................................................................................ o Lain-lain : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Sistem kardiovaskuler a. TD : .........................................b. N :Nadi Karotis: Teraba|_|Tidak Teraba |_|Nadi perifer: Kuat|_|Lemah|_|Tidak Teraba |_|Perdarahan :..cc Lokasi.c. HR : d. Keluhan Nyeri Dada : |_| ya |_| Tidak P : Q : R : S : T : e. Irama jantung : |_| reguler |_| iregulerf. Suara jantung : |_| normal ( S1/ S2 tunggal ) |_| mur-mur |_| gallop |_| lain-lain ...............................................................................................................g. Ictus Cordis : ............................................................................................................................h. CRT : ..................................detik i. Akral : |_| hangat |_| kering |_| merah |_| basah |_| Pucat |_| panas |_| Dingin j. Siklus perifer : k. JVP : l. CVR : m. CTR : n. ECG & interpresentasinya : .........o. Obat jantung yang diberikan : ......

4. Sistem persyarafan a. S : b. GCS : c. Refleks fisiologis |_| patella |_| triceps |_| biceps d. Refleks patologis |_| babinsky |_| brudzinsky |_| kernig e. Keluhan pusing |_| ya |_| Tidak P : Q : R : S : T : f. Pemeriksaan saraf kranial : N 1 : |_| normal |_| tidak Ket : ....................................................................N 2 : |_| normal |_| tidak Ket : ....................................................................N 3 : |_| normal |_| tidak Ket : ....................................................................N 4 : |_| normal |_| tidak Ket : ....................................................................N 5 : |_| normal |_| tidak Ket : ....................................................................N 6 : |_| normal |_| tidak Ket : ....................................................................N 7 : |_| normal |_| tidak Ket : .....................................................................N 8 : |_| normal |_| tidak Ket : .....................................................................N 9 : |_| normal |_| tidak Ket : .....................................................................N 10 : |_| normal |_| tidak Ket : .....................................................................N 11: |_| normal |_| tidak Ket : .....................................................................N 12: |_| normal |_| tidak Ket : .....................................................................g. Pupil |_| anisokor |_| isokor Diameter : ........./..........h. Sclera |_| anikterus |_| ikterus i. Konjunctiva |_| ananemis|_| anemis j. Tanda PTIKMuntah Proyektil|_|Nyeri Kepala Hebat|_|k. Curiga fraktur cervicalJejas klavikula|_|Battle Sign|_|Bloody rinorhoe|_|Bloody Otorhoe|_|Brill Hematome|_|l. Tekanan Intra Kranial (ICP)..mmm. Obat neurologi yang diberikan (dosis)..n. Istirahat/ Tidur : .........................Jam/ Hari o. IVD : p. EVD : q. ICP : r. Lain-lain : ....5. Sistem perkemihan a. Keberdihan genetalia b. Sekret : c. Ulkus d. Kebersihan meatus ureta : e. Keluhan kencing Bila ada, Jelaskan : .....

f. Kemampuan berkem