Professional Documents
Culture Documents
OLEH
B Diaphoresis: Ya Tidak
L Riwayat Kehilangan cairan berlebihan: Diare Muntah Luka bakar
O IVFD : Ya Tidak, Jenis cairan:
O Lain:
D Masalah Keperawatan:
Kesadaran: Composmentis Delirium Somnolen Apatis Koma
GCS : Eye ... Verbal ... Motorik ...
Pupil : Isokor Unisokor Pinpoint Medriasis
Refleks Cahaya: Ada Tidak Ada
Refleks fisiologis: Patela (+/-) Lain-lain
Refleks patologis : Babinzky (+/-) Kernig (+/-) Lain-lain ... ...
BRAIN
Masalah Keperawatan:
Nyeri : Ada Tidak
Problem : .......................... Qualitas/ Quantitas : ..........................
Regio : .......................... Skala : ..........................
Timing : .......................... Kekuatan otot : ..........................
BONE
Leher :
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Dada :
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E ___________________________________________________________________
A
D
Abdomen dan Pinggang :
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O ___________________________________________________________________
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Masalah Keperawatan:
Hasil Laboratorium :
a. Hasil Pemeriksaan Darah Lengkap
Hasil
No Parameter Satuan Nilai rujukan
Hasil
No Parameter Satuan Nilai rujukan Remark
1 pH - 7,35 7,45
2 PCO2 mmHg 35,00 -45,00
3 PO2 mmHg 80,00 100,00
4 HCO3- mmol/L 22,00 26,00
5 BE (B) mmol/L -2 - 2
6 SPO2 % 95 % - 100%
7 TCo2 mmol/L 24-30
8 K mmol/L 3,5-5
9 Na mmol/L 135-145
10 Cl mmol/L 95-105
12 Ca mmol/L 1-1,25
13 Hb g/dL 11,5-15,5
ANALISA DATA
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PERENCANAAN
Hari/ No Rencana Keperawatan
Tanggal Dx Tujuan dan Kriteria Hasil Intervensi Rasional
PELAKSANAAN
Hari/ No
Jam Tindakan Keperawatan Respon Klien TTD
Tanggal Dx
CATATAN PERKEMBANGAN
Hari/ No Jam S O A P
Tgl Dx