UNIVERSITAS ALMA ATA YOGYAKARTA

FAKULTAS ILMU-ILMU KESEHATAN

PROGRAM STUDI PROFESI NERS
Jl. Ringroad Barat Daya No.1, Tamantirto, Bantul, Daerah Istimewa Yogyakarta
Tlp. (0274)434 2288, 434 2277. Fax. (0274)4342269. Web: www.almaata.ac.id

I.

Identitas Diri Klien (RM.....................................:

Nama

: ..............................................
.................................................

Suku

Umur

: ..............................................

Agama

Pendidikan

: ...............................................

Status Perkawinan :

Jenis Kelamin

:................................................

Pekerjaan

Alamat

: ..............................................
.................................................

Lama Bekerja

...............................................
...............................................

II.

Tanggal masuk RS

:................................................

Sumber Informasi

: ..............................................

Tanggal Pengkajian :

Riwayat Penyakit
1. Keluhan Utama Saat Masuk RS:
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
2. Riwayat Penyakit Sekarang:
.........................................................................................................................................................
.........................................................................................................................................................
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3. Riwayat Penyakit Dahulu
.........................................................................................................................................................
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4. Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan:

Masalah atau Dx medis pada saat masuk rumah sakit

.........................................................................................................................................................
............................
...............................................................................................................................................................
Tindakan yang telah dilakukan di poliklinik atau UGD
.........................................................................................................................................................
.........................................................................................................................................................
Penanganan kasus
.........................................................................................................................................................
.........................................................................................................................................................
III.

Pengkajian saat ini

1. Persepsi dan Pemeliharaan Kesehatan
.........................................................................................................................................................
.........................................................................................................................................................
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2. Pola Nutrisi/Metabolic
Program diit RS:
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Intake makanan:

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Intake cairan:
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
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3. Pola Eliminasi

a.

Buang air besar

....................................................................................................................................................
....................................................................................................................................................
b.

Buang air kecil

....................................................................................................................................................
....................................................................................................................................................

4. Pola aktifitas dan latihan:

Kemampuan Perawatan Diri
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM

Kesimpulan:

Oksigenasi .....................................................................................................................................
..................
......................................................................................................................................................
5. Pola Tidur dan Istirahat
.........................................................................................................................................................
.........................................................................................................................................................
6. Pola Persepsual
.........................................................................................................................................................

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7. Pola Persepsi Diri
.........................................................................................................................................................
.........................................................................................................................................................
8. Pola Seksualitas dan Reproduksi
.........................................................................................................................................................
.........................................................................................................................................................
9. Pola Peran Hubungan
.........................................................................................................................................................
.........................................................................................................................................................
10. Pola Managemen Koping-Stess
.........................................................................................................................................................
.........................................................................................................................................................
11. Sistem Nilai dan Keyakinan

12. Kenyamanan dan Nyeri

IV.

Pemeriksaanfisik
Keadaan umum:
Kesadaran
:
TD:
mmHg
BB/TB
:
Kepala

Leher

Thorak

Abdomen

P:

x/m

N:

x/m

S:

Inguinal

Ekstrimitas

Program terapi :

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