Professional Documents
Culture Documents
IDENTITAS
1. Nama Pasien :
2. Umur:
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :
KELUHAN UTAMA
1. Keluhan utama:
5. Lain-lain:
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- Genogram :
Jenis................................................ Flow..............lpm
Ventitalor
Mode :
FiO2 :
PEEP :
SaO2 :
Vol. Tidal:
I:E Ratio:
Lain-lain :
i. Penggunaan WSD:
- Jenis : ......................................................................................................................
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- Jumlah cairan : ......................................................................................................................
- Undulasi :......................................................................................................................
- Tekanan : ......................................................................................................................
j. Tracheostomy: ya tidak
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k. Lain-lain:
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f. Hoffman/Tromer test :
g. Pupil anisokor isokor Diameter: /......
h. Sclera anikterus ikterus
i. Konjunctiva ananemis anemis
j. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ........................
k. IVD :................................................
l. EVD :................................................
m. ICP :................................................
n. Lain-lain:
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o. Tanda-Tanda PTIK:
p. Gangguan pendengaran: Ada Tidak , Jelaskan:
q. Gangguan penglihatan : Ada Tidak, Jelaskan:
r. Gangguan Penciuman ; Ada Tidak, Jelaskan
f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .......................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : .. ml/jam
Warna :............
Bau :........
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : cc/hari parenteral : cc/hari
k. Balance cairan:
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o. Lain-lain:
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o. Lain-lain:
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8. Sistem Endokrin
a. Pembesaran tyroid: ya tidak Masalah Keperawatan :
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak
d. Hiperglikemia: ya tidak
e. Lain-lain:..................Jelaskan:..................................................
j. Lain-lain:
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PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
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PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)
TERAPI
Surabaya, ..20...
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PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
ANALISIS DATA
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PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
TANGGAL: .................................
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2.
3.
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6.
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RENCANA INTERVENSI
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IMPLEMENTASI DAN EVALUASI KEPERAWATAN
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