FORMAT PENGKAJIAN

Nama Mahasiswa
NIM
Ruangan
Tanggal Pengkajian

: Arif Soeprijono
: 0960084
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:
Jam

IDENTITAS
Nama Pasien
Umur
Jenis Kelamin
Suku Bangsa
Pekerjaan
Pendidikan
Alamat
Tanggal MRS
Diagnosa Medis

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KELUHAN UTAMA :
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RIWAYAT KESEHATAN :
1. Riwayat Kesehatan/Penyakit sekarang :
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Riwayat Kesehatan/Penyakit dahulu :
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Riwayat Kesehatan/Penyakit keluarga :

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Genogram :
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POLA FUNGSI KESEHATAN :

1. Pola penatalaksanaan kesehatan / persepsi sehat
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Masalah Keperawatan :
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2. Pola Nutrisi
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Masalah Keperawatan :
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3. Pola Eliminasi
Eliminasi Alvi
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Eliminasi Uri
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Masalah Keperawatan :
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4. Pola Istirahat dan tidur
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Masalah Keperawatan :
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5. Pola Aktifitas
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Masalah Keperawatan :
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6.

Pola kognitif perseptual keadekuatan alat sensori

a. Penglihatan, perasa, pembau
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b. Kemampuan bahasa, belajar, ingatan dan pembuatan keputusan
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Masalah Keperawatan:
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7. Pola persepsi dan konsep diri

a. Gambaran diri
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b. Harga diri
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Ideal diri
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Peran
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Identitas diri
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Masalah Keperawatan :
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8. Pola Reproduksi Seksual
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Masalah Keperawatan :
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9.

Pola hubungan peran

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Masalah Keperawatan :
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10. Mekanisme Koping
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Masalah Keperawatan :
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11. Pola tata nilai dan kepercayaan
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Masalah Keperawatan :
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PEMERIKSAAN FISIK
Status kesehatan umum
Kesadaran :
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TTV :
Suhu : ...............................................................................
TD
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RR
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Nadi : ..............................................................................
PEMERIKSAAN HEAD TO TOE
1. Kepala dan Leher
a. Kepala
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b. Muka
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c. Mata
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d. Telinga
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e. Hidung
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f. Mulut dan faring
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g. Leher
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2.

Thorak
a. Inpeksi
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b. Palpasi
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c. Perkusi
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d. Auskultasi
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3. Abdomen
a. Inpeksi
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b. Palpasi
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c. Perkusi
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d. Auskultasi.
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4.

Inguinal, genital dan Anus

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5. Integumen
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6. Muskuloskeletal neurologis
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7.
Neurologis
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Dextra

Refleks : Fisilogis
Dextra

Sinistra

Sinistra

Triceps

Biceps

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Dextra

Dextra

Sinistra

Achiles

Knee

Patologis
Dextra

Sinistra

Sinistra

Dextra

Babinski

Sinistra

Oppenheim

Dextra

Sinistra

Chadok
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PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium Tanggal : .............................., Jam : .......................
PEMERIKSAAN

HASIL

NILAI NORMAL

2. Pemeriksaan Laboratorium Tanggal : .............................., Jam : .......................

PEMERIKSAAN

HASIL

NILAI NORMAL

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3. Pemeriksaan Laboratorium Tanggal : .............................., Jam : .......................

PEMERIKSAAN

HASIL

NILAI NORMAL

Pemeriksaan Radiologi
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1. Pemeriksaan Lain lain
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2. Terapi
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DAFTAR MASALAH KEPERAWATAN

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Surabaya,
Mahasiswa

Arif Soeprijono
Nim : 096 0084

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