FORMAT PENGKAJIAN

PRAKTEK BELAJAR KLINIK

KEBUTUHAN DASAR MANUSIA / MEDICAL SURGICAL

I. DATA DEMOGRAFI
A. Biodata
Nama :
Usia/Tgl.Lahir :
Jenis Kelamin :
Alamat :
Suku Bangsa :
Status Pernikahan :
Agama :
Pekerjaan :
Diagnosa Medik :
No. Medical Record :
Tanggal Masuk :
Tanggal Pengkajian :
Therapi Medik :
B. Nama Penanggung Jawab
Nama :
Usia :
Jenis Kelamin :
Pekerjaan :
Hubungan Dengan Klien :

II. Keluhan Utama

Pasien masuk RS dengan keluahan muntah disertai darah setelah minum obat
OAT selama 2 hari, timbul keluhan secara tiba-tiba, upaya mengatasi adalah
segera dibawa ke Rumah sakit.
III. Riwayat Kesehatan Masa Lalu
A. Riwayat Kesehatan Sekarang
Pasien 1 minggu yang lalu pernah di rawat di Rumah Sakit dengan keluhan batuk-batuk
disertai darah. Pasien mengatakan sudah batuk selama 2 bulan dan sudah berobat ke
Puskesmas tetapi hanya diberi obat batuk biasa.
Pasien mengatakan setelah dirawat di Rumah Sakit pasien sudah merasa kondisinya
membaik.

1
 B. Riwayat Kesehatan Lalu

Pasien mengatakan pada masa kecil tidak pernah menderita batuk dan tidak pernah
dirawat di RS. riwayat pemakaian obat yaitu Glibenklamide 2 x 1

C. Riwayat Kesehatan Keluarga

Genogram tiga generasi.

D. Riwayat Psichososial

Orang terdekat dengan klien adalah suami. Interaksi dalam keluarga, pola
komunikasi secara verbal, Pembuat keputusan adalah suami klien, keluarga
tampak cemas. Hal yang sangat dipikirkan saat ini : penyakit yang tidak
sembuh-sembuh , harapan setelah menjalani perawatan : sembuh dan dapat
aktivitas kembali, perubahan yang dirasakan setelah jatuh sakit : merasa tidak
berdaya. p
IV. Riwayat Spiritual
Sebelum sakit klien aktif dalam megikuti ibadah keagamaan dan kegiatan-
kegiatan keagamaan lainnya.

V. Pemeriksaan Fisik
A. Keadaan Umum Klien
Klien nampak lemas
B. Tanda-Tanda Vital
Suhu :
Nadi :
Respirasi :
Tekanan Darah :
C. Sistem Pernafasan
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

2
D. Sistem Cardio Vaskuler

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
E. Sistem Pencernaan

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

F. Sistem Indera
1. Mata : ..........................................................................................................................
..........................................................................................................................
2. Hidung: ........................................................................................................................
..........................................................................................................................
3. Telinga .........................................................................................................................
..........................................................................................................................
G. Sistem Saraf
1. Fungsi Cerebral : ............................................................................................................

2. Fungsi Cranial : ..............................................................................................................

3. Fungsi Motorik : .............................................................................................................

4. Fungsi Sensorik : ............................................................................................................

5. Fungsi Cerebellum: .........................................................................................................

6. Reflex ..............................................................................................................................

7. Iritasi Meningen: .............................................................................................................

H. Sistem Muskulo Skeletal

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
I. Sistem Integumen
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
J. Sistem Endokrin
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

3
 K. Sistem Perkemihan
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
L. Sistem Reproduksi
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
M. Sistem Immun
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
VI. Aktivitas Sehari-hari
A. Nutrisi :
B. Cairan :
C. Eliminasi :
D. Istirahat Normal :
E. Olah Raga :
F. Rokok / Alkohol :
G. Personal Hygiene :
H. Aktivitas/Mobilitas Fisik :
I. Rekreasi :

VII. Test Diagnostik

..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
VIII. Therapi Saat Ini

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