#umla
PN2%#$%N PR%"%'%N RUM%+ *%$' UMUM !%R%+ %BUP%'N %BUP%'N BU'ON U'%R%
Nama
.................................................................... ................... : .................................................
Umur
: .......... thn ............ bln ............. hari; L / P
..................................................................... ..................... No. RM : ................................................
Beri tanda (√) pada kolom yang sesuai: Sumber informasi: _ Pasien _ Orang lain, Nama: ............................................ ............................................ Hubungan dengan pasien: ............................................. ............................................. _ $ursi roda _ #rankar Tanggal pengkajian: ....... / ......... / ! ....., Pukul ................. "ara masuk: _ #erjalan _ &'( _ _ %sal pasien: _ Poliklinik Hasil pemeriksaan )ang diba*a: _ +ab ........................................... ........................................... Obat-obatan dari ruma: No
Nama Obat
_ adiologi ......................................... ......................................... _ +ain-lain ....................... !osis
"aktu
$eluarga terdekat )ang dapat dihubungi: .......................................................... .......................................................... Hubungan dengan pasien: .............................................. .............................................. %lamat: ................................................. .......................................................................... .................................................... ..................................................... ............................... ..... Telp/Hp.......................................... elp/Hp...................................................... ............
$. R$"%&%' *+%'%N ............................................................................. ................................................. ................................................... ...................................................... ................................................... ............................... ....... eluan utama : .................................................... .......................................................................... ..................................................... ................................................... ................................................. ................................ ........ ,. Riaya Riayatt kesea keseatan tan sekara sekarang ng: ............................................... .......................................................... ....................................................................................... ......................................................... ............................................................. ............................................................... ......................................................... ........................... ............................................................................. .................................................. ................................................. .................................................... ................................................. ...................... !iagnosis Masuk : ................................................... . Riaya Riayatt medi mediss yang yang perna perna dialam dialamii tandai )ang sesuai: _ 'angguan jantung _ 'angguan tiroid _ Hipertensi _ Pen)akit %utoimun ....................................... ....................................... _ Tuberkulosis _ Hernia operasi / tdk operasi _ #atuk lama _ Hepatitis % / # / " / ( / 0 _ %sma/#ronkhitis/Pneumonia/0mfisema _ 'angguan saluran 1erna dan/atau empedu _ i*a)at ke1elakaan _ (iare / Tifoid / (emam berdarah _ Stroke / Paralisis _ 'angguan ginjal/prostat/kandung kemih _ $ejang demam _ (ialisis _ 2raktur / (islokasi / %rtritis/Sendi tak stabil _ Pen)akit 3enular Seksual _ (iabetes _ +ain-lain .................................................. ........................................................................... .................................... ........... (ira*at di rumah sakit terakhir kali .................................................................... ............................................................................. ......... Selama .......................... hari, dengan diagnosis pen)akit ................................................. ........................................................................... .................................................. ................................................. .................................................... ....................................... ............ ......................................................... Haid: teratur / tdk teratur /. Ria Riaya yatt eam eamil ilan an: ' .... P .... % .... HPHT ......................................................... _ Obat-obatan _ %lkohol _ $etergantungan obat/alkohol _ Tdk ada ketergantungan 0. ebiasaan: _ okok
1. Ria Riaya yatt aler alergi gi: _ Tidak _ 4a, ................................................. ......................................................................... .................................................. ..................................................... .................................................... ............................. .... _ 4a, *aktu terakhir ...................................... 5enis ................... Sejumlah ....................... kantong Transfusi darah: _ Tidak _ %da, ................................................. eaksi )ang timbul: _ Tidak ada ......................................................................... ................................................. .................................................... ........................... $$. '$N2%' *%!%R%N ,. . /.
............................. 0 ................. 3 ................. 6 ................. 2las 2lasgo go 3oma 3oma *4al *4alee: ............................. esadaran: _ "ompos mentis _ Somnolen _ Sopor _ $oma _ .......................................................... _ Terjaga _ Orientasi _ 3engantuk _ Non-responsif _ (isorientasi _ Tersedasi *tatus Mental _
_ Tertidur
,.
_ 'elisah
_ #erespon pada perintah
_ Han)a berespon pada n)eri
$$$. PMR$*%%N 5$*$ 'inggi Badan ................ 1m 'anda 6i 6ital: T(: ................... mmHg P: .............. 7/mnt N: ..................... 7/mnt S: ..................... "o _ 89 _ 9 _ 9 _ 9 _ teratur _ tidak teratur ualitas nadi: _ ! Posisi saat diukur:............................................... diukur:.................................................................. ................... Nursing Assessment Form Page 1 of 6
PN2%#$%N PR%"%'%N RUM%+ *%$' UMUM !%R%+ %BUP%'N BU'ON U'%R% .
Rambut dan kepala :
_ bersih _ kotor _ ada benjolan
_ luka, kondisi luka .................................................................. /.
0. 1. 7.
8. 9.
Nama
: ....................................................................
Umur
: .......... thn ............ bln ............. hari; L / P
No. RM : .....................................................................
_ mudah ter1abut _ +ain-lain ...................................................... _ lingkar kepala ................................... 1m
_ tdk ada keluhan _ sekret _ lensa kontak _ ka1amata _ sklera ikhterik _ 1ekung, $anan - $iri _ konjungti
ing _ Stridor Bunyi Napas : _ 6esikuler Mata:
#antung : i1tus 1ordis, lokasi .................................................................... Bunyi #antung : _ S8/S murni reguler _ ireguler _ murmur _ gallop _ (atar _ %s1ites _ "ekung _ "embung _ +ingkar perut: .............. 1m . %bdomen: _ (efans mus1ular _ Soepel _ (istensi abdomen _ Hepatomegali _ massa _ n)eri tekan _ sonor/hipersonor _ timpani _ +ain-lain ................................................................................................................................................................ _ baik _ buruk 'urgor: Bising usus: _ normal _ tidak ada _ hiperaktif _ minimal 2rek ...........7/mnt _ tidak ada _ %da, jenis ................................ $ondisi: ................................................................................. *toma : 6esika urinari _ teraba _ tidak teraba ,;. 2enitalia : _ kotor _ bersih _ ada, jumlah ........................................ 11 Pengeluaran 4airan: _ tidak ada _ hipospadia _ sekret _ lain-lain ...................................................................................................................... Uretra : %lat bantu berkemi: _ tidak ada _ &nserted/$ondom kateter, hari ke ...................... _ haemoroid _ lesi _ perdarahan _ prolaps _ iritasi _ lain-lain ...................................... %nus: ,,. kstremitas: _ gerak bebas _ gerakan terbatas, karena....................................................... ..................................................
_ +emah otot _ hemiparese _ Paraparese _ n)eri otot _ $aku otot _ N)eri sendi _ &nkoordinasi _ $elelahan _ $ebas _ %mputasi _ (eformitas _ Tremor, pada ................................... . _ Spider nea
_ Paralisis
'onus Otot:
ekuatan motorik: ! 8 A ! 8 A ! 8 A ! 8 A _ lurus _ lordosis ,. Punggung: bentuk tulang belakang:
ROM:
_ kifosis
_ Nursing Assessment Form Page 2 of 6
PN2%#$%N PR%"%'%N RUM%+ *%$' UMUM !%R%+ %BUP%'N BU'ON U'%R% _ t.a.k. _ normal
$ulit : Barna:
Nama
: ....................................................................
Umur
: .......... thn ............ bln ............. hari; L / P
No. RM RM : .....................................................................
_ +esi/luka, kondisi ..................................................................................................................... ...................................................................... _ kemerahan _ pu1at _ n)eri punggung
$6. PN2%#$%N R$*$O #%'U+> $N'2R$'%* UL$'> N&R$> LU% LU%> !%N NURO*N*OR$ ,.
a. Risiko #atu (Morse Fall Scale) 5aktor Risiko
i*a)at ja tuh dalam C! hari terakhir
*kala
b. Risiko $ntegritas ulit (Norton Skin !ntegrity Risk Assessment) *kor
R$'R
%$;
,
/
Ti Tidak d ak = !
3obilitas
3andiri penuh
%gak terbatas Sangat terbatas
!mmo"ile
4a = 8A
Status 3ental
Terjaga penuh
$adang bingung
+etargi/$oma
Be rest /dgn bantuan pera*at
!
Status Nutrisi
Tongkat/#alker
8A
#aik; habis EA@ "ukup; "ukup; A!-E@ #uruk; FA!@ porsi Per selang/&6 porsi porsi
Perabot/Furniture
!
$ondisi $ulit Se1ara Dmum
Turgor baik
%brasi/kemerahan
Turgor buruk, edema, eritema
$ering,atropi
&nkontinensi
Tidak ada
Drinari
2ekal
Drinari dan 2ekal
$ondisi 2isik Se1ara Dmum
#aik
"ukup
#uruk
Sangat buruk
4a = A (iagnosis sekunder
Tidak = !
%lat bantu berjalan
&6/Heparin +o1k
*OR
Tidak = ! 4a = !
Sangat bingung
'a)a berjalan Normal/Berest /!mmo"ile
!
+emah
8!
Terganggu
!
'O'%L
Status mental Orientasi sesuai kemampuan
!
3elupakan keterbatasan diri
8A
'otal *kor LeAel Risiko #atu
.
_ N)eri
Pengka?ian Nyeri
_ Tidak n)eri
Provokes/ Pemi1u ............................................................ ................................................................................... Pattern/Pola: /Pola: _ 3enetap _ &ntermitten _ Situasional Quality .................................................................................... Regio Re gio .............................. .............................................................................................. .............................. Scale ......................................... _ Skala !-8! _ Skala Bajah $ime ............................................................................................. 0kspresi *ajah: .......................................................... ...................................................................................... 3enjaga 3enjagaarea area)g )gsakit sakit ........................................................
_ tidur _ akti
/.
_ 'idak ada luka saat ini
Pengka?ian Luka
'RA!NA%&/('(R
NOMOR LU(%
B,
B.
B/
B0
B1
B7
+O$%S&
D$D,%N
S$A%&
Re
PN2%#$%N PR%"%'%N RUM%+ *%$' UMUM !%R%+ %BUP%'N BU'ON U'%R%
Nama
: ....................................................................
Umur
: .......... thn ............ bln ............. hari; L / P
No. RM : .....................................................................
ernig sign _ 4a _ Tidak Babinski _ 4a _ Tidak 3addo4k: _ 4a _ Tidak Brudinsky: _ 4a _ Tidak 2enggaman tangan: ............................................ Pemeriksaan NerAus arnial: NerAus $: ................................................................ NerAus $$:................................................. NerAus $$$> $6> 6$:................................... NerAus 6: .............................................................. NerAus 6$$: ............................................. NerAus 6$$$: .......................................... NerAus $C: ............................................................ NerAus C: ............................................... NerAus C$: ............................................ NerAus C$$: ................................................................ 6. POL% %'$6$'%* +%R$%N !%N *'%'U* 5UN2*$ON%L ,.
$stiraat dan 'idur _ tidak ada kelainan
_ sulit tidur
_ gelisah
+ama tidur: Siang ......... jam 3alam ........ jam Hal-hal )ang membantu 1epat tidur:
_ minum susu/teh hangat _ mandi/1u1i muka/kaki .
_ tidak memuaskan saat bangun _ sering terbangun malam hari _ dibantu obat _ tanpa obat &nsomnia: _ 4a _ Tidak
_ memba1a _ mematikan lampu _ mendengarkan musik _ lain-lain ................................................................................................................
Hal lain................................................................................................................................................................................................... Makan dan Minum $eluhan: _ mual _ muntah _ anoreksia _ t.a.k _ lain-lain ........................................ 3akan .................. 7/hr 5enis: ................................................ Pantangan ...................................................................... Porsi )ang dihabiskan .............................................................. %lergi ............................................................................................. (iet khusus: _ tidak _ 4a, jenis ......................................... 5umlah kalori ................... ## terakhir.......... kg Sekarang .........kg (iet per ..... _ oral 3inum .................. 11/hr _ 4a %kses intra
_ selang/tu"e jumlah ............11 / hari _ akses &6 5enis ................................................................. _ Tidak _ "entral line: "6"/P&""? Dkuran .............................
_ +okasi
_ Terapi 1airan ........................ ........... tetes/menit makro/mikro ? /. liminasi: B%B: _ keras _ lunak _ en1er tdk berbentuk 2rekuensi #%#: ........ 7/hr _ darah segar _ tanpa lendir G darah Barna ........................................ _ berlendir _ $onstipasi _ i*.3elena _ Obat laksatif ............................... Terakhir #%# ............... hari )ang lalu _ (iare _ biasa _ rasa terbakar _ disuria _ inkontinensia _ urgensi 2rekuensi #%$: ....... 7/hr
_ keseringan
_ nokturia
'angguan di atas dialami sejak ........... hari )ang lalu
0. 1. 7. 8.
_ putus-putus
_ retensi
_ (iuretik ......................................... _ Tidak
_ tidak puas _ frek. berubah _ Barna urin....... 5umlah .............
i*a)at pen)akit ginjal/saluran ken1ing: _ 4a ebersian !iri 3andi ............ 7/hari Sikat gigi ........... 7/hari $eramas ..................... 7/minggu _ tidak _ jarang _ rutin, .................... 7/minggu/bulan Olaraga:
_ sesak %ktiAitas se4ara umum: respon terhadap akti
%$&%
'$!%
%. Pera*atan 3inimal 8. $ebersihan diri, mandi, ganti pakaian dilakukan sendiri . 3akan dan minum dilakukan sendiri . %mbulasi dengan penga*asan . Obser
6$. R*PON MO*$> R$"%&%' *O*$%L-ONOM$-BU!%&%-*P$R$'U%L
. Pergantian posisi dan obser
Nursing Assessment Form Page 4 of 6
PN2%#$%N PR%"%'%N RUM%+ *%$' UMUM !%R%+ %BUP%'N BU'ON U'%R%
Nama
: ....................................................................
Umur
: .......... thn ............ bln ............. hari; L / P
No. RM : .....................................................................
1. dan Perkembangan _ #erdiri _ #erbi1ara ,. Pertumbuan Respon mosi +ing. $epala skrg: .......... 1m %S& sampai umur .......... hr/bln/thn _ takut terhadap terapi/pembedahan/lingkungan S _ gelisah 0. !iet _ menangis ## lahir : ........... gr Susu formula sjk ........... hr/bln/thn _ _ _ 3inuman formula %S& Susu botol _ _ _ senang rendah diri sedih P# : .......... 1m 3akanan tmbhn ............ bln/thn _ 3akanan saring _ 3akan di meja _ marahneonatus: _ mudah tersinggung _ 1emas / tegang _ Tidak 3asalah 1. Na
Peran dlm struktur keluarga .......................................... $onflik/masalah dalam keluarga ................................................................. menyim*ang secara "ermakna............................................................ ari nilai normal PMR$*%%N PNUN#%N2 _ menarik _uraikan $ehidupan sosial: _$C. t.a.k diri isolasiyang sosial 2obia/ketakutan ,. Laboratorium: %gama: ......................................... 3enjalankan ibadah _ 4a _ Tidak _ $adang-kadang _ #utuh bantuan pemuka agama $e)akinan terhadap pen)embuhan .................................................................................................................................................... . Pemeriksaan /. omunikasi !iagnostik:
_ afasia _ gagap _ parau _ pelo a. 6erbal: _ normal /. Radiologi: _ is)arat _ tulisan b. Non
_0............................................................... Riayat $munisasi:
.
Nursing Assessment Form Page 65 of 6
