BAGIAN KEPERAWATAN DASAR KLINIK

FORMAT PENGKAJIAN KESEHATAN

UJIAN PRAKTEK

Nama Pasien : Tanggal Masuk :

Umur : Tanggal Pengkajian :
No. RM : Dx. Medis :

A. PENGKAJIAN
1. Riwayat Kesehatan
a) Alasan Masuk
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b) Riwayat Kesehatan Sekarang
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c) Riwayat Kesehatan Dahulu
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d) Riwayat Kesehatan Keluarga
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2. Pemeriksaan Fisik
a) Keadaan Umum :
b) Kesadaran :

c) Tanda-tanda Vital
1) Tekanan darah :
2) Nadi :
3) Pernafasan :
4) Suhu :

d) Head to Toe
1) Kepala
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2) Mata
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3) Hidung
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4) Telinga
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5) Mulut
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6) Leher
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7) Thorax
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8) Jantung
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9) Abdomen
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10) Genetalia
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11) Ekstremitas
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3. Pemeriksaan Penunjang
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4. Pengobatan
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 B. DIAGNOSA DAN NURSING CARE PLANNING
No. Diagnosa NOC NIC Implementasi Evaluasi
No. Diagnosa NOC NIC Implementasi Evaluasi
C. PROSEDUR TINDAKAN
No. Tindakan Rasional
No. Tindakan Rasional
No. Tindakan Rasional