Form Awal Kprwtn

8/19/2019 Form Awal Kprwtn

http://slidepdf.com/reader/full/form-awal-kprwtn 1/5

RSMH Palembang ASESMEN AWAL PASIEN RAWAT INAP RM 003 (RM 03 Revisi)

Hal 1-9

I. ASESMEN KEPERAWATAN

Barcode

Nama :Tanggal Lahir : No.RM :

Ruang Rawat :Tanggal sesmen : !u"ul :

A. INFORMASI UMUMT# : $$$$$$$ %m ## : $$$$$$$ "gTe"anan &arah : $$$$$$$ mmHg ' Na&i : $$$$$$$ mnt ' *uhu : $$$$$$$ o+ ' !erna,asan: $$$$$$ meniton&isi saat masu" : Man&iri i/a/ah Tem/at ti&ur $$$$$$$$$$$$$$$ lergi : Ti&a" a 2enis $$$$$$$$$$$$$$$ seut"an $$$$$$$$$$$$$$$$$$$$$$$$$ eutuhan "husus : Ti&a" a&a lat antu &engar a%a mata Tong"at 4igi /alsu $$$$$$$$

B. DATA PSIKOLOGIS, SOSIAL EKONOMI DAN SPIRITUAL#i%ara : 5elas Ti&a" &a/at &imengerti $$$$$$$$$$$$$$$$$$$ omuni"asi : 6eral Non veral /atis*tatus emosional : *tailtenang +emasTa"ut Marah

Riwa7at /ernah mengalami gangguan 2iwa &i masa lalu : Ti&a" a "a/an $$$$$$$$$$$$$$$$ Riwa7at Trauma : Ti&a" &a nia7a ,isi" /si"ologis RT nia7a *e"sual!er"osaan

Tin&a"an riminal $$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$ Riwa7at einginan &an !er%oaan #unuh iri : Ti&a" &a $$$$$$$$$$$$$$$$$$ *"or *a& !erson :$$$$$ ategori : Ringan *e&ang #erat

Status mental

lam /erasaan : *esuai *e&ih !utus asa eta"utan 4emira erleihan

,e" : *esuai atar Tum/ul Ti&a" sesuai8ntera"si selama wawan%ara : oo/erati, #ermusuhan Ti&a" "oo/erati,

Mu&ah tersinggung onta" mata "urang $$$$$$$$$$$$$$$$$$$$$$$$ eutuhan s/iritual /asien &alam /erawatan &i rumah sa"it : !asien me mutuh"an "onseling s/iritualagama !asien memutuh"an antuan &alam men2alan"an ia&ah &an men7etu2uin7a $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

C. PEMERIKSAAN FISIK 1. SIRKULASI

"stremitas : Hangat ingin *ianosis $$$$$$$$$$$$$$$$$$ !engisian "a/iler : 3&t" ;3 &t"

ia,oresis : &a Ti&a" a&aon2ungtiva : !in" !u%at&ema : Ti&a" a &i$$$$$$$$$$$$$$$$$$$$ sites : Ti&a" a!er&arahan : Ti&a" a &i$$$$$$$$$$$$$$$$$$ %%

2. RESPIRASI 5alan Na,as: #eas Ti&a" eas &isea"an oleh : !ang"alli&ah2atuh */utum arah */asme #en&a sing *uara na,as : 6esi"uler <he=ing *tri&or Ron%hi !ola na,as : /neu 7s/neu #ra&i/neu Ta"i/neu >rtho/neu 8rama Na,as : Teratur Ti&a" teratur !enggunaan otot antu na,as : Retra"si &a&a +u/ing hi&ung 5enis /erna,asan : Pernafasan dada Pernafasan perut Lain-lain .............................................

3. NEUROSENSORI

eluhan : Ti&a" a&a !using esemutan e2ang elemahan lo"asi : $$$$$$$$$$$$

Mata : Normal 4angguan seut"an $$$$$$$$$$$$$$$$$$$ Telinga : Normal 4angguan seut"an $$$$$$$$$$$$$$$$$$$

Hi&ung : Normal 4angguan seut"an $$$$$$$$$$$$$$$$$$$

Ting"at esa&aran : ewasa : $$$$ M$$$$$ 6$$$$ #alita ? Tahun : $$ 6$$ !$$$ @$



4. ASESMEN NYERI

Numeri% Rating *%ale +om,ort *%ale &i RM 01A

Lo"asi n7eri : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ 8ntensitas (s"ala1-10): s"ala $$$$$$$$$$$$ Bre"uensi n7eri: Terus menerus 8ntermitten"a&ang-"a&ang 5arang!en2alaran : $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ "s/resi wa2ah : Tenang Meringis Menangis Men2erit-2erit

8ntegritas ulit : Ti&a" a&a lu"a &a Lu"a 5elas"an $$$$$$$$$$$$$$$$$$$$$$$ (5i"a a&a lu"a serta"an Form Pengkajian Keperawatan Luka)Dekubiu! : Ti&a" a &i $$$$$$$$$$$$$$$$$$$$$$$$ era2a& l ll lll l6

Resi"o Lu"a e"uitus (*"or #ra&en) : Resi"o Ren&ah (*"or C0 D C3) Resi"o *e&ang (*"or 1? D 19) Resi"o Tinggi (*"or 11 D 1A) Resi"o *angat Tinggi (*"or E D 10)

". AKTIFITAS DAN ISTIRA#AT

Rentang 4era" : R>M a"ti, R>M /asi, e,ormitas : Ti&a" a&a &a regio $$$$$$$$$$$$$$ 4angguan Ti&ur : Ti&a" a $$$$$$$$$$$$$$$$$$$$

Massatonus otot:

SKRINING TINGKAT KETERGANTUNGAN PASIEN $SKALA DOUGLAS%:

ategori 8 : !erawatan Minimal (self care) memerlu"an wa"tu 1 D C 2am CA 2am ategori 88 : riteria !erawatan !artial (Intermediate Care) memerlu"an wa"tu 3 D A 2am CA 2am ategori 888 : riteria !erawatan Ma"simal ( Total Care / Intensif Care) memerlu"an wa"tu ? D E 2am CA 2am

ASSESMEN RESIKO &ATU# 'SKALA MORSE( $PADA DE)ASA USIA * 1+ TA#UN ATAU SUDA# MENIKA#%

ila"u"an Total *"or $$$$$$$$$ Ti&a" ila"u"an ategori Ting"atan Resi"o 5atuh (er&asar"an nilai total s"or):

Resi"o Ren&ah RR ( 0 D CA ) Resi"o *e&ang R* ( C? D AA ) Resi"o Tinggi RT ( F A?) ASSESMEN RESIKO &ATU# 'SKALA #UMPTY DUMPTY( $PADA ANAKANAK - 1+ TA#UN%

ila"u"an Total *"or $$$$$$$$ Ti&a" ila"u"an Ting"atan risi"o 2atuh /asien : Risi"o 5atuh Ren&ah (s"or G D 11) Risi"o 5atuh Tinggi (s"or F 1C)

Total s"or minimal I G &an Total s"or ma"simal I C3

. NUTRISI DAN CAIRAN

5enis &iet : Nasi iasa !uasa $$$$$$$$$$$$$$$ !orsi : $$$$$$$$$$$$$$$$$$ Tue ,ee&ing : Ti&a" &a $$$$$$$$$$$$$$$$$ eluhan : Ti&a" a&a Na,su ma"an Mual Muntah

4angguan mengun7ah 4angguan menelanTurgor: lastis Ti&a" elastis

SKRINING GI/I A)AL DENGAN MST $MALNUTRITION SCREENING TOOL%

P00ee Sk A

1. /a"ah /asien mengalami /enurunan erat a&an 7ang ti&a" &iren%ana"anti&a" &iingin"an &alam E

ulan tera"hirJ

Ti&a" Ti&a" 7a"in (a&a tan&a : a2u%elana men2a&i leih longgar) a a&a /enurunan erat a&an sean7a":

0C

o 1 D ? "g

o E D 10 "g

o 11 D 1? "g

o ; 1? "g

o Ti&a" tahu era/a "g /enurunann7a

C. /a"ah asu/an ma"an /asien er"urang "arena /enurunan na,su ma"an "esulitan menerimaMa"anan J

Ti&a" a

1C3A

C

01

RSMH Palembang ASESMEN AWAL PASIEN RAWAT INAP RM 003 (RM 03 Revisi) Hal 2-9



T>TL *>R .........

Bi0 !k * 2, 50!ie6 bee!ik 06ui!i

SKRINING GI/I A)AL $ K#USUS IBU #AMIL %

P00ee Sk A

1. /a"ah /asien tam/a" "urus Ja. Ti&a"

. aC. &a gangguan metaolisme (Mgangguan ,ungsi tiroi&in,e"si "ronis se/erti :

H868*T#Lu/uslain-lain seut"an ............................................ )a. Ti&a" . a

3. &a /ertamahan ## 7ang "urang atau leih selama "ehamilan :a. Ti&a"

. a

A. Nilai H# K 10 g&l atau H+T K 30 :

a. Ti&a" . a

7

1

7

1

7

1

7

1

T>TL *>R : ..............

Bi0 !k * 2, 50!ie6 bee!ik 06ui!i

8.ELIMINASIBre"uensi ## : $$$$$$$$$$ hr#ising @sus : $$$$$$$$$$$ mnteluhan ## : Ti&a" a&a !er&arahan Hemorroi& onsti/asi iareara"teristi",e%es : !a&at Luna" +air<arna ,e%es: $$$$$$$$$$$$$$$ Bre"uensi # : $$$$$$$$$ %%2am <arna @rin : $$$$$$$$$$$$$$$$$$$$$$$$$$

D. ASESMEN KEPERA)ATAN K#USUS $ ANAK 9 LAN&UT USIA 9 PSIKIATRI %

$ :e ;06< i=0k =ibuu>k06 %

1. ASESMEN K#USUS ANAK $USIA 7 9 1+ TA#UN%

#era/a "ali /ernah &irawat: 1 "ali C "ali 3 "ali ; &ari 3 "ali *ia/a orang ter&e"at &gn ana" : 7ah 8u a"a" &i" $$$$$$$$$$$$$$$ /a"ah ana" merasa ter/isah saat &irawat : a ti&a"

Rea"si ana" saat &irawat: Menangis Men7en&iri $$$$$$$$$$$$$$$$$$ !engasuh : >rang tua 7ah 8u Nene" *au&ara $$$$$$$$$$$$$ !emawaan umum : !eriang !en7en&iri !emalu !emerani $$$$$$$$$$$$$$$ eiasaan /erila"u uni" : &a Ti&a" $$$$$$$$$$$$$$$$$$$$$$$$$$ Riwa7at tumuh emang:

*8 s.& umur $$$$ tahun M!*8 $$$$$ ulan Teng"ura/ $$$$$ ulan Merang"a" $$$$$ ulan #er&iri $$$$ ulan #er2alan $$$$$$ ulan Riwa7at 8munisasi : #+4 !T 1 C 3 !olio 1 C 3 He/atitis +am/a" Lain-lain .......................

2. ASESMEN K#USUS LANSIA $USIA ? "" TA#UN%

K6=i!i @i!ik =06 e60

a. !ernah 5atuh : Ti&a" a $$$$$$$$$$$$$$$$$$$ ulan tahun 7ang lalu

b. ontra"tur N7eri gera" : Ti&a" a &i$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ c. Mengguna"an alat #antu : Ti&a" Tong"at ursi ro&a $$$$$$$$$$$$$$$$$$$$$$$$ d. *"ala e/resi : Ti&a" &e/resi (1 D A) Risi"o &e/resi (? D 9) e/resi (; 9) e. Memori : #ai" *ering lu/a Ti&a" ingat f. *tatus Minimental : #ai" (0 D C) 4angguan intele" ringan (3 D A)

ASESMEN KEPERAWATAN

Barcode

Nama :

Tanggal Lahir : No.RM : No RM :Ruang Rawat :Tanggal sesmen : !u"ul :

RSMH Palembang ASESMEN AWAL PASIEN RAWAT INAP RM 002 (RM 03 Revisi) Hal 3-9



4angguan intele" se&ang (? D G) 4angguan intele" erat ( D 10)

3. ASESMEN K#USUS PSIKIATRI

Faktor Predisposisi

!erse/si (halusinasi) : Ti&a" a&a !en&engaran !englihatan !eraaan !enge%a/an !en%iuman !roses /i"ir : *esuai #lo%"ing !engulangan /emi%araan #er/utar-/utar $$$$$$$$$$$$$$$

8si !i"ir : *esuai >sesi Boia !i"iran magis $$$$$$$$$$$$$$$ <aham : Ti&a" a&a gama +uriga eesaran $$$$$$$$$$$$$$$$$$ Ting"at "ogniti, : oheren #ingung *tu/or mematung isorientasi (wa"tutem/atorang) Memori &a7a ingat : #ai" Ti&a" ai" Ting"at "onsentrasi &an erhitung : #ai" Ti&a" ai" Menging"ari /en7a"it 7ang &i&erita : Ti&a" a $$$$$$$$$$$$$$$$$$$$$

5i"a salah satu &ari /oin &iatas erma"na a&a gangguan /si"iatri &ila"u"an s"or ssesmen Resi"o 5atuh *"ala

&monson Total s"or : $$$$$$$$ ategori : Ti&a" eresi"o 2atuh(*"or K 90) #eresi"o 2atuh(*"or F 90)

RSMH Palembang ASESMEN AWAL PASIEN RAWAT INAP RM 003 (RM 03



E. KEBUTU#AN EDUKASI1.

2.

3.

F. DIAGNOSIS KEPERA)ATAN

1.

2.

3.

!erawat 7ang meng"a2i

( ........................................ ) Nama 2elas &an Tan&a tangan

Documents

Form Awal Kprwtn