PENGKAJIAN AWAL PASIEN RAWAT INAP
Petunjuk: Beri tanda (√) pada kolom yang sesuai
LABEL PASIEN Nama
: Tn. “A”
No. RM : 191404
m!"
: #4 Ta$!n
J%n&' K%am&n
: La&*a&
A+ama
: I'am
P%%",aan
: P%-an&
S!!Ban+'a
: B!+&'
Aama-
: Jn. Lo/&*o/& Ma"o'
S-a-!' P%"n&a$an
: M%n&a$
&a+no'a M%2&'
: 3I AIS
1. T&5a T&5a 2&"! 2&"!an an+a +ann :Ta :Tan++a n++a: : 04 J!& J!& 6017 6017 P! P!! !:: 08. 08.00 00 W&-a 6. P%n+a,&an P%n+a,&an :Tan+ :Tan++a: +a: 0 J!& 6017 P!!: 09.40 W&-a W&-a &/%"o%$ 2a"& : N. “M” 3!5!n+an 2%n+an /a'&%n: I'-"& ;.
$%" 4. A'a ma'! : G Po&&n& '/%'&a&' Po&&n& !m!m P"&5a2& o-%"
TRSIAE
RS a&n
o-%" !a"
PENGKAJIAN MEIS ( ?KTER ) ANAMNESE 1. K%!$a K%!$ann !-ama !-ama : (m!a& (m!a&== ama= ama= /%n>%-! /%n>%-!'): '):
LL
K%'a2a"an m%n!"!n '%,a 4 $a"& an+ a! '%5%!m ma'! RS. S%'a (@)= "&aao/%"a'& 2%n+an 2&a+no'% m%anoma ma&+na= '!2a$ /%"na$ %mo-%"a/& '%5ana ; '&!' 2an "a2&o-%"a/& 10 a&= "&aa- M (*)= "&aa- 3T (@). 6. R&aa- /%na&- '%a"an+ : M%anoma ma&+na ;. R&aa- /%na&- 2a$!! : (-%"ma'! "&aa- o/%"a'&) Pa'&%n /%"na$ 2&no/%"a'& '%5%!mna 2%n+an 2&a+no'% m%anoma ma&+na 2an 4. 7. . #.
'!2a$ %mo-%"a/& ; '&!' 2an ,!+a "a2&o-%"a/& 10 '&!'. R&aa- /%na&- 2aam %!a"+a : Pa'&%n m%m&&& "&aa- $&/%"-%n'& 2a"& aa$ /a'&%n. R&aa- /%%",aan A/aa$ /%%",aan /a'&%n 5%"$!5!n+an 2%n+an Ca- * Ca- 5%"5a$aa ( m&'ana: &m&a= +a' 2) D -&2a a= '%5!-an : S-a-!' %onom& : 5a& '%2an+ !"an+ R&aa- a%"+& : a. ?5a-: T&2a Fa= '%5!-an : 5. Maanan: T&2a Fa= '%5!-an : >. a&n*a&n :
PEMERIKSAAN MM 1. K%a2aan !m!m : Tam/a -&2a 'a&Tam/a 'a&- "&n+an Tam/a 'a&- '%2an+ Tam/a 'a&- 5%"aKom/o' m%n-&' A/a-&' 2. K%'a2a"an : So/o" ;. G
Koma : E: 6
M: 4
Somno%n-
: 6 PENGKAJIAN KEPERAWATAN ANAMNESE
1. Tan++a : 1 Jan!a"& 6017 P!! : 09.40 6. &/%"o%$ 2a"& : N. “M” 3!5!n+an 2%n+an /a'&%n : I'-"& ;. R&aa- %'%$a-an '%a"an+ (aa'an ma'! R!ma$ Sa&-) : K%'a2a"an m%n!"!n '%,a 4 $a"& an+ a! '%5%!m ma'! RS. S%'a (@)= "&aao/%"a'& 2%n+an 2&a+no'% m%anoma ma&+na= '!2a$ /%"na$ %mo-%"a/& '%5ana ; '&!' 2an "a2&o-%"a/& 10 a&= "&aa- M (*)= "&aa- 3T (@). 4. Aa- %'%$a-an an+ -%"/a'an+ : Jenis
Keterangan
RL: 7 68 -/m !"an 18 11 -" NRM
Jenis
Keterangan
7. R&aa- %'%$a-an an+ a! (2&"aa-= o/%"a'&): Pa'&%n /%"na$ 2&no/%"a'& '%5%!mna 2%n+an 2&a+no'% m%anoma ma&+na 2an '!2a$ %mo-%"a/& ; '&!' 2an ,!+a "a2&o-%"a/& 10 '&!'. . R&aa- /%na&- %!a"+a : T&2a a2a A2a : o &a5%-%' o Kan%" o A'ma o 3&/%"-%n'& o Jan-!n+ o La&nna : #. R&aa- /%m%"&'aan /%n!n,an+ an+ /%"na$ 2&a!an : Jenis
Bagian yg
Pemeriksaan
Diperiksa
Ra2&oo+& La5o"a-o"&!m
Lembar
T&2a a2a
A2a
Keterangan
Ho-o -$o"a' 3%ma-oo+& K&m&a 2a"a$
8. R&aa- a%"+& :
T&2a a2a
J%n&' /%n%5a5 a%"+&
A2a (,&a a2a= '&aan &'& oom 2&5aa$ &n& ) R%a'& an+ -&m5!
9. R&aa- -"an'!'& 2a"a$ : B%!m /%"na$ P%"na$= a/an : T&m5! "%a'& a%"+& D: T&2a Fa= "%a'& a%"+& an+ -&m5! : 10. R&aa- %mo-$%"a/& : B%!m /%"na$ P%"na$= a/an : S!2a$ 5%"a/a a& D : /a'&%n '!2a$ %mo-%"a/& ; '&!' 11. R&aa- "a2&o-$%"a/& : B%!m /%"na$ P%"na$= a/an D : S!2a$ 5%"a/a a& D :Pa'&%n '!2a$ "a2&o-%"a/& '%5ana 10 a& PEMERIKSAAN HISIK 1. K%'a2a"an : 6. ;. 4.
7.
a 5. N%"& 2a2a : T&2a Fa= '%5!-an : >. %n!- na2& : T%"a-!" T&2a -%"a-!" 2. S&"!a'& : A"a $an+aA"a 2&n+&n Ra'a %5a' Pa/&-a'& E2%ma= Loa'& : %. P!'a'& : K!aL%ma$ La&n*a&n : R%'/&"a'& : a. Poa naa' : No"ma B"a2&/n%a Ta>$&/n%a 5. o!m% /%"naa'an : No"ma 3&/%"%n-&a'& 3&/o%n-&a'&
2&"& '%n2&"&
o M%m5a$aaan o"an+ a&n
Jika Terpasang Restrain Perhatikan Keadaan aerah Restrain
2. P%n+a,&an Pa'&%n Ja-!$ 1) P%n+a,&an /a'&%n ,a-!$ 2%a'a ( Mo"'% Ha S>a% ) No
T&n+a- R%'&o
1. R&aa- ,a-!$ an+ 5a"! a-a! 2aam ; 5!an -%"a$&" 6.
&a+no'a m%2&' '%!n2%"
Aa- 5an-! ,aan *B%2"%'- 2&5an-! /%"aa*P%no/an+= -on+a- a%" *H!"n&-!" 4. P%n+o5a-an M%maa& -%"a/& I T%"a/& '%2a-&= na"o-&= /'&o-"o/&a 7
Saa T&2a 0 Fa 67 T&2a 0 Fa 67
3a'& 0
0 17 ;0 T&2a 0 10 60
0
67
;.
“"%'&o "%n2a$ 67*70 a!an &n-%"%n'&”
0 10 60 0 10
10
10 0 45
"%'&o -&n++& : 71 a!an &n-%"%n'& ,a-!$ "%'&o -&n++&
2)
P%n+a,&an 2an /%n>%+a$an /a'&%n R%'&o ,a-!$ !n-! G%"&a-"& T!&' n&a& '%'!a& 2%n+an $a'& /%n+a,&an
No 1. 6. ;. 4. 7. . #.
T&n+a- "%'&o Gan++!an +aa 5%",aan (&'%"%-= m%n+$%n-a=5%"a!n ) P!'&n+ /&n+'an /a2a /o'&'& -%+a K%5&n+!n+an '%-&a/ 'aaNo-!"&a &non-&n%n'&a K%5&n+!n+an &n-%"m&--%n K%%ma$an !m!m ?5a-*o5a-an 5%"%'&o -&n++& ( 2&!"%-&= na"o-&='%2a-& An-&/'&o-&= a'an-&= a'o2&a-o"= an-&a"&-m&a An-& $&/%"-%n'&= o5a- $&/o+&%m&= an-&2%/"%''an N%!"o%/-& 8. R&aa- Ja-!$ 2aam a-! 16 5!an '%5%!mna 9. ?'-%o/o"o'&' 10. Gan++!an /%n2%n+a"an 2an a-a! /%n+&$a-an 11. '&a 0 -a$!n %a-a' T?TAL NILAI So" : 1*; "%'&o "%n2a$
1;. E&m&na'& : a. BAB : 5. BAK :
Saa Tan++a 4 ; ; ; 6 6 6 6 6 1 1 1
1 ;
So": 4 R%'&o T&n++&
No"ma Kon'-&/a'& M%%na Inon-&n%n'&a A& I%o'-om
14. S%'!a"%/"o2!'& : a. Wan&-a M%n'-"!a'& /%"-ama= !'&a : T$= Lamana '&!': 3a"& • M%no/a!'% : B%!m S!2a$= M%n'-"!a'& -%"a$&" : • T&2a Fa &'an+a • 3am& : Tan++a $a&2 -%"a$&" : • T&2a Fa= -%"a$&" -an++a : • P%m%"&'aan /a/ 'm%a" : P%m%"&'aan /a!2a"a '%n2&"& : T&2a Fa= SGMamo+"a& -%"a$&" • -an++a P%n++!naan aa- on-"a'%/'& : T&2a Fa= ,%n&' : • P%"ma'aa$an '%'!a"%/"o2!'&= '%5!-an : • 5. La&*a& : S&"!m'&'& : T&2a Fa Ma'aa$ /"o'-a- : T&2a Fa 17. K%5!-!$an om!n&a'&/%n2&2&an 2an /%n+a,a"an : a. B&>a"a : No"ma Gan++!an 5&>a"a= '%"an+an aa a/an D 5. Ba$a'a '%$a"&*$a"& : In2on%'&a= a-&/a'& In++"&'= a-&/a'& a%"a$= '%5!-an : B!+&' La&n*a&n= '%5!-an :
>. P%"! /%n%",%ma$ : 2. 3am5a-an 5%a,a" :
T&2a Fa= 5a$a'a : Ba$a'a &'a"a- : Fa T&2a T&2a Fa : o Ba$a'a o <%ma' o Ko+n&-& o Emo'& o P%n2%n+a"an o 3&an+ m%mo"& o Mo-&a'& 5!"! o Ma'aa$ /%n+&$a-an o K%'!&-an 5&>a"a o S%>a"a &'&oo+& -&2a mam/! 5%a,a"
La&n*a&n : %. a o A!2&o*&'!a +am5a" . T&n+a- /%n2&2&an : o TK o S o SMP o SMA Aa2%m& P%"+!"!an T&n++& o La&n *a&n : +. Pa'&%n a-a! %!a"+a m%n+&n+&nan &no"ma'& -%n-an+ : P"o'%' /%na&T%"a/& a-a! o5aLa&n*a&n 1. S/&"&-!a : a. A+ama: I'am P"o-%'-an Ka-$o& 3&n2! B!2$a Kon+$!>! La&n*a&n : 5. M%n+!n+a/an %/"&$a-&nan an+ 5%"$!5!n+an 2%n+an "aaIna/ : T&2a Fa : o K%-&2amam/!an !n-! m%m/%"-a$anan /"a-% '/&"&-!a '%/%"-& 5&a'a o P%"a'aan n%+a-& -%n-an+ ''-%m %/%">aaan -%"$a2a/ '/&"&-!a o Kon& an-a"a %/%">aaan '/&"&-!a 2%n+an %-%n-!an '&'-%m %'%$a-an o La&n*a&n : 1#. S&'-%m 'o'&a : a. P%%",aan :
W&"a'a'-a P%+aa& 'a'-a P%n'&!n PNSTNIP?LRI La&n*a&n : P%-an& 5. T&n++a 5%"'ama : I'-"& ?"an+ -!a Ana T%man S%n2&"& La&n*a&n : >. Kon2&'& &n+!n+an 2& R!ma$ : Kon2&'& an-a& : L&>&n T&2a &>&n
o
Tan++a "!ma$ :
T&2a a2a
A2a : o A2a /%+an+an o T&2a a2a /%+an+an P%n%"an+an : &n -&2a a2a /%+an+an) K%5%"'&$an &n+!n+an : B%"'&$ (-&2a a2a 5a"an+ m%m5a$aaan) T&2a 5%"'&$ (a2a 5a"an+ m%m5a$aaan)
PENGKAJIAN GIOI (& &'& o%$ A$& G&C&) S"&n&n+ G&C& A'!/an maanan !"an+ 2a"& 1 6 2a"& an+ 2&on'!m'&= a-a! 1 6 %5!-!$an '%ama %5&$ 2a"& # $a"& P%n!"!nan BB %5&$ 2a"& 10 2aam 5!an -%"a$&". La5o"a-o"&!m : A5!m&n Q ;.7 G" 2 Perencanaan a.
P%"! 2&%- $!'!' :
&a5%-%' m%&-!' ?5%'&-a' Kan%" P%na&- /a"! "on&' 3&/%"-%n'& ( T 140 100 mm 3+ ) Gan++!an !n+'& $a-& (SG?T 100 SGPT . 100 ) Gan++!an !n+'& G&n,a : IR=
To-a So" : J&a Q 6= &%- an+ 2&5%"&an : B&a'a T&m L!na Sa"&n+
a. P%n&a&an '-a-!' G&C& : 1) An-"o/om%-"& : TB : . R%n>ana /%na-aa'anaan G&C& : En%"+ : Ka P"o-%&n: G" L%ma: G"
DAFTAR MAALA! K"P"RA#ATA$
N%"& :
K%'%ama-an /a'&%n
T!m5!$ %m5an+
Poa -&2!"
N!-"&'&
S!$! T!5!$
Mo5&&-a'a-&&-a'
E&m&na'&
P%"!'& ,a"&n+an
In-%+"&-a' !&-
P%n+%-a$!anom!n&a'&
Kon& /%"an
P%"aa-an 2&"&
K%'%&m5an+an
Jaan naa'/%"-!a"an +a' La&n*a&n : Poa naa' R"$%A$A P"RA#ATA$ &$T"RD&&PL&$ ' R"F"RAL
1. 2. 3. 4. 5. 6.
&%- 2an N!-"&'& : T&2a Fa : R%$a5&&-a'& m%2&> : T&2a Fa : Ha"ma'& : T&2a Fa : P%n+o5a-an '%'!a& &n2&a'& Wo!n2
P%"aa-an an,!-an an+ 2&5%"&an 2&"!ma$ : P%"aa-an 2&"& (Man2&= BAB= BAK) Ban-!an a-&&-a' &'& (>"!->$%'= !"'& "o2a= 2) P%"aa-an !a Ban-!an m%2&'/%"aa-an '%a-!*a-! (3om% >a"%) P%n2am/&n+an -%na+a $!'!' 2& "!ma$ Tan++aP!!
B&2an
P%"aa-
P%man-a!an 2&%Pan-a!an /%m5%"&an o5aLa-&$an &'& an,!-an (HT)
A$& G&C&
Tan2a Tan+an Nama ! Bila pengkajian persalinan tidak dilakukan, kolom tanda tangan bidan diberi tanda silang "bidan tidak tanda tangan)
