FORMAT PENGKAJIAN

I. DATA DEMOGRAFI
A. Biodata
-

Nama ( nama lengkap, nama panggilan )

: .

Usia / tanggal lahir

: .....

Jenis kelamin

Alamat ( lengkap dengan no.telp )

: .

Suku / bangsa

: .

Status pernikahan

: .

Agama / keyakinan

: .

Pekerjaan / sumber penghasilan

: .

Diagnosa medik

: .

No. medical record

: .

Tanggal masuk

: .

Tanggal pengkajian

: .

B. Penanggung jawab
-

Nama

: .

Usia

: .

Jenis kelamin

: .

Pekerjaan / sumber penghasilan

: .

Hubungan dengan klien

: .

STEVEN-GIA

II. Pengkajian Primer

A. Airway
Prioritas intervensi tertinggi dalam primary survey adalah mempertahankan jalan
napas (dalam hitungan menit, tanpa oksigen akan menyebabkan truma cerebral
yang akan dapat berkembang menjadi kematiaN otak ( anoxic brain death)
.................................................................................................................................
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B. Breathing
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C. Circulation
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D. Disability
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E. Eksposure
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III. Pengkajian Kondisi Mental
Alert ( ) Respon Verbal ( ) Respon Nyeri/Pain ( ) Tidak Berespon/unresponsible ( )
IV. Pengkajian Sekunder
A. Riwayat kesehatan sekarang
1. Alasan Masuk RS
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
2. Keluhan Utama
.
3. Riwayat Keluhan Utama

STEVEN-GIA

B. Riwayat kesehatan lalu

A. Riwayat Penyakit yang pernah dialami
.
B. Riwayat Perawatan
.
C. Riwayat Operasi
.
D. Riwayat alergi
.
E. Riwayat Merokok
.
F. Riwayat Imunisasi
.

C. Riwayat kesehatan keluarga

1. Penyakit yang diderita anggota keluarga:
.
2. Genogram :

STEVEN-GIA

D. RIWAYAT PSIKOSOSIAL

E. PEMERIKSAAN FISIK
Keadaan umum klien
1. Tanda-tanda distress

a. Gawat jantung atau pernapasan

Dada seperti terlilit Dispnea Batuk Mengi
Lainnya
b. Nyeri
Berkeringat Melindungi area yang nyeri
Lainnya
c. Ansietas atau depresi
Wajah cemas Gerakan resah Telapak tangan basah dan dingin
Lainnya..
2. Penampilan dihubungkan dengan usia

:.

3. Tinggi badan

:..................cm

Berat badan

: ..Kg

4.

5. Kesadaran
CM

Apatis Delirium/Gelisah Somnolen/ letargi/Optudansi

Stupor Koma

STEVEN-GIA

Tanda-tanda vital
1. Suhu

: 0C

2. Nadi

:..x/menit

3. Pernafasan

:..x/menit

4. Tekanan darah

:...mmHg

HEAD TO TOE
1.

Kepala

2.

Wajah

3.

Leher

STEVEN-GIA

4.

Dada

5.

Abdomen

6.

Genitalia dan Pelvis

7.

Tulang Belakang

8.

Ekstremitas

STEVEN-GIA

VII. TEST DIAGNOSTIK

..

...

...

...

...

...

...

..

...

VIII. Therapy saat ini

1.

2.

3.

4.

5.

6.

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7.

8.

9.

STEVEN-GIA