POLITEKNIK KESEHATAN RS dr.

SOEPRAOEN
PROGRAM STUDI KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl Praktik :

PENGKAJIAN
1. Identitas Klien
Nama : No. RM :
Usia : Tanggal Masuk :
Jenis kelamin : Tanggal Pengkajian :
Alamat : Sumber Informasi :
No. Telepon : Nama klg. dekat yang bisa dihubungi:
Status pernikahan :
Agama : Status :
Suku : Alamat :
Pendidikan : No. telepon :
Pekerjaan : Pendidikan :
Lama bekerja : Pekerjaan :

2. Keluhan
a. Alasan masuk rumah sakit:











b. Keluhan saat pengkajian:











3. Riwayat penyakit sekarang:















4. Riwayat penyakit masa lalu:















5. Riwayat kesehatan keluarga:

6. Riwayat Psikososial Spiritual:

a. Psikologis








b. Sosial








c. Spiritual








7. Pola Aktivitas Sehari-Hari (di Rumah dan RS)

N KEBIASAAN DI RUMAH DI RUMAH SAKIT

O
1. Makan

2. Minum
3. Eliminasi
BAK

4. Eliminasi
BAB

5. Istirahat/tidu
r

6. Aktivitas/lati
han olahraga
dll
8. Pemeriksaan Fisik
1. Keadaan umum :

..
Kesadaran :

...
K/U :

...
2. Tanda tanda vital
Tekanan Darah: .mmHg Suhu :
0
C
Nadi : .x/menit RR :
x/menit
Tinggi Badan : .cm Berat Badan :
..kg

3. Kepala & Leher

a. Kepala








b. Mata







cc. Telinga







d. Hidung








e. Mulut

f. Leher








4. Pemeriksaan Integumen/kulit dan kuku








5. Pemeriksaan Payudara dan Ketiak








6. Thorak & Dada
Thorax
- Inspeksi : ..........................................................................................
..........................................................................................................

.
- Palpasi : ...........................................................................................
..........................................................................................................

.
- Perkusi : ............................................................................................
..........................................................................................................

.
- Auskultasi : .......................................................................................
..........................................................................................................

.
Jantung
Inspeksi : ..........................................................................................
..........................................................................................................

.
Palpasi : ...........................................................................................
..........................................................................................................

.
Perkusi : ............................................................................................
..........................................................................................................

.
Auskultasi : .......................................................................................
..........................................................................................................

.
7. Abdomen
Inspeksi : ..........................................................................................
..........................................................................................................

.
Palpasi : ...........................................................................................
..........................................................................................................

.
Perkusi : ............................................................................................
..........................................................................................................

.
Auskultasi : .......................................................................................
..........................................................................................................

.

8. Genitalia & Anus

Inspeksi : ..........................................................................................
..........................................................................................................

.
Palpasi : ...........................................................................................
..........................................................................................................

.

9. Ekstremitas (kekuatan otot, kontraktur, deformitas, edema, luka,

nyeri/nyeri tekan, pergerakan)
Atas : .......................................................................................................
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Bawah ......................................................................................................
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Tonus Otot
9. Hasil Pemeriksaan Penunjang (Laboratorium, USG, Rontgen, MRI)
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10. Terapi (Medis, RehabMedik, Nutrisi)
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Malang,
Pengkaji

__________________

ANALISA DATA

NAMA PASIEN :

UMUR :

DX MEDIS :

DATA PENUNJANG ETIOLOGI MASALAH

 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN :

UMUR :
DX MEDIS :

N
TGL MUNCUL DIAGNOSA KEPERAWATAN TGL TERATASI TTD
O
 CATATAN PERKEMBANGAN

NAMA PASIEN :

UMUR :

DX MEDIS :

NO. DX TGL / JAM CATATAN PERKEMBANGAN TTD

 RENCANA ASUHAN KEPERAWATAN

Nama / Usia : Dx / No.Reg :

N Dx Keperawatan Tujuan & Kriteria Hasil Intervensi Rasional TTD

o
 CATATAN KEPERAWATAN

Nama / Usia : Dx / No.Reg :

N Tgl NO. TINDAKAN KEPERAWATAN EVALUASI TTD

o DX