Professional Documents
Culture Documents
Format Askep
Format Askep
B. Riwayat Penyakit
1. Keluhan utama saat masuk rumah sakit
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C. Pengkajiaan Keperawatan
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1. Pola Nutrisi/Metabolik
Program diit di rumah sakit
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Intake makanan
Sehari-hari
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Intake cairan
Sehari-hari
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Saat ini (kondisi sakit)
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2. Pola Eliminasi
BAB
Sehari-hari
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BAK
Sehari-hari
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Oksigenasi…………………………………………………………………………………………………………………………………………………………………………..
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5. Pola Perceptual
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D. Pemeriksaan Fisik
2. Tingkat kesadaran
3. Tanda-tanda vital
4. Pemeriksaan sistemik
b. Mata:
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c. Telinga
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d. Hidung:
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e. Mulut:
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f. Leher:
1) Kelenjar tiroid
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3) Kaku kuduk:
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1) Inspeksi
Bentuk dada:……………………………………………………………..............
Deviasi trakhea:…………………………………………………………………
Jejas : …………………………………………………………………………….
Pengembangan dada : ……………………………………………………………
2) Palpasi
Focal fremitus:……………………………………………………………………
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3) Perkusi
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4) Auskultasi
Suara nafas:………………………………………………………………………
Suara tambahan:……………………………………………………………………
h. Kardiovaskuler
2) Perkusi
Batas jantung kiri:…………………………………………………………………
Batas jantung kanan:………………………………………………………………
Batas atas jantung:…………………………………………………………………
3) Auskultasi
BJ I:………………………………………BJ II:…………………………………
BJ III:………………………Murmur:……..……………….Gallop:……………...
i. Abdomen
1) Inspeksi
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2) Auskultasi
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3) Palpasi
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4) Perkusi
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k. Perkemihan
1) Inspeksi
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2) Palpasi VU
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3) Perkusi ginjal:
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1) Inspeksi :
Bengkak: …………………………..Deformitas: ………………………………...
Dislokasi :……………………………Pemendekan:………………………………
2) Palpasi
Krepitasi :…………………………………………………………………………
5P (Pain, Palor, Parestesia, Pulselesness, Paresis):
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Uji kekuatan otot:
Gerakan :………………………………………………………………………….
m. Integumen
1) Inspeksi:
Keutuhan kulit:……………………………………………………………………
Tekstur kulit:………………………………………………………………………
Warna kulit:……………………………………………………………………….
Perubahan setempat (distribusi lesi, susunan lesi, jenis lesi):……………………
2) Palpasi
Kelembaban kulit:…………………………………………………………………
Turgor kulit:……………………………………………………………………….
Letak/kedalaman lesi (bila ada) :………………………………………………….
n. Endokrin
1) ABI:………………………………………………………………………………...
2) Deteksi dini kaki diabetik:…………………………………………………………
o. Persyarafan
Saraf II:
Saraf III:
Saraf IV:
Saraf V:
Saraf VI:
Saraf VII:
Saraf VIII:
Saraf IX:
Saraf X:
Saraf XI:
Saraf XII:
Inspeksi:
Hemiplegia Hemiparese
2) Dermatome test
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E. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
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PENGELOMPOKAN DATA
Data Subyektif
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Data Obyektif
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Penguji, Mahasiswa,
Tanggal……………………………. Tanggal...…………………
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ANALISIS DATA