FORMAT PENGKAJIAN UJIAN STAGE ANAK

Tgl/jam MRS :
Ruang :
No. Register :
Dx. Medis :
Tgl. Pengkajian :

IDENDITAS PASIEN
Nama : .............................. Suami/Istri/Orangtua : ..............................
Umur : .............................. Nama : ..............................
Jenis Kelamin : .............................. Pekerjaan : ..............................
Agama : .............................. Alamat : ..............................
Suku/Bangsa : .............................. Penanggung jawab
Bahasa : .............................. Nama : ..............................
Pendidikan : .............................. Alamat : ..............................
Pekerjaan : .............................. : ..............................
Status : ..............................
Alamat : ..............................
: ..............................

KELUHAN UTAMA
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RIWAYAT PENYAKIT SEKARANG
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Upaya yang telah dilakukan: ......................................................................................................
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Terapi yang telah diberikan: ........................................................................................................
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RIWAYAT KESEHATAN DAHULU
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RIWAYAT KESEHATAN KELUARGA
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Genogram:

KEADAAN LINGKUNGAN YANG MEMPENGARUHI TIMBULNYA PENYAKIT

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POLA FUNGSI KESEHATAN
1. Pola persepsi dan tata laksana kesehatan
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2. Pola nutrisi dan metabolisme
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3. Pola eliminasi
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4. Pola aktivitas
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5. Pola istirahat-tidur
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6. Pola kognitif dan persepsi sensori
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7. Pola konsep diri
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8. Pola hubungan peran
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9. Pola seksualitas
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10. Pola mekanisme koping
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11. Pola nilai dan kepercayaan
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 PEMERIKSAAN FISIK
1. Status kesehatan umum
Keadaan/penampilan umum : ............................ GCS : ................
BB sebelum sakit : ............................ TB : ................
BB saat ini : ............................
BB ideal : ............................
Perkembangan BB : ............................
Status gizi : ............................
Status hidrasi : ............................
Tanda-tanda vital
TD : ............................
N : ............................
Suhu : ............................
RR : ............................

2. Kepala
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3. Leher
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4. Thorax
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5. Abdomen
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6. Tulang belakang
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7. Ekstremitas
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8. Genetalia dan anus
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9. Pemeriksaan neurologis
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PEMERIKSAAN PENUNJANG/DIAGNOSTIK

1. Laboratorium
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2. Radiologi
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3. Pemeriksan lain-lainnya.
TERAPI

1. Oral
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2. Parenteral
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3. Lain-lain
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.................................., ................
Mahasiswa,

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NPM