RM 2.

Program Pendidikan Profesi Ners Keperawatan Manajemen

Program Studi S1 Keperawatan
STIKES MUHAMMADIYAH LAMONGAN
Jl. Raya Plalangan Plosowahyu Lamongan Telp/Fax. (0322) 323457
Email : stikesmuhla@yahoo.com

Tanggal Masuk : ___________________ Jam Masuk : ___________________

Ruang/kelas : ___________________ Nomor MR : ___________________

IDENTITAS
Nama : _____________________ Nama Orang tua : ___________________
Umur : _____________________ Umur : ___________________
Jenis Kelamin : Laki-laki / Perempuan Pekerjaan : ___________________
No. Reg : _____________________ Agama : ___________________
Alamat : _____________________ Pendidikan : ___________________
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RIWAYAT SAKIT DAN KESEHATAN

Keluhan Utama :
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Riwayat Penyakit Sekarang :

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Riwayat Penyakit Dahulu :

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Riwayat yang pernah diderita keluarga :

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Riwayat alergi : Ya Tidak

Jelaskan
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Riwayat Pesalinan
Pre natal
Umur Kehamilan : _______ Minggu
Riwayat Abortus : Ya :_________ Tidak
Penyakit Penyerta : _________________________________________________________
Natal
Jenis Persalinan : Spontan Persalinan dengan Bantuan SC
Lama Persalinan : _______________________________________________________
Komplikasi Persalinan : _______________________________________________________
Lain-Lain : _______________________________________________________
Post natal
Apgar Score : Berat Badan : cm
Lingkar Dada : cm Lingkar Lengan : cm
Panjang Badan : cm Lingkar Kepala : cm

RIWAYAT IMUNISASI
Imunisasi Wajib
BCG Hepatitis 1 Hepatitis 2 Hepatitis 3 Campak 1 Campak 2
Polio 0 Polio 1 Polio 2 Polio 3 Polio 4 Polio 5
DPT 1 DPT 2 DPT 3 DPT 4 DPT 5

Imunisasi Tambahan
Hib 1 Hib 2 Hib 3 Hib 4 HPV
Pneumokokus 1 Pneumokokus 2 Pneumokokus 3 Pneumokokus 4 Hepatitis A
Influenza MMR 1 MMR 2b Tifoid Varisela
Masalah
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Riwayat Tumbuh Kembang

Pertumbuhan
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Perkembangan
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Tahap perkembangan psikososial
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Gerakan kasar dan halus

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ROS (REVIEW OF SYSTEM)

Observasi & Pemeriksaan Fisik
Keadaan Umum : Baik Cukup Kurang
Kesadaran : _______________________________________________________
Tanda-tanda vital : TD_______________mmHg N _______________ x/menit
0
S ________________ C RR_______________ x/menit

PERNAFASAN B1 (BREATH)
Pola Nafas
Irama : Teratur Tidak teratur
Jenis : Dipsnue Kusmaul Ceyne Stoke Lainya _____________________
Suara nafas : Vesikuler Stridor Wheezing Ronchi Lainya _________
Sesak nafas : Ya Tidak
Batuk : Ya Tidak
Masalah _______________________________________________________________________
KARDIOVASKULER B2 (BLOOD)
Irama jantung : Teratur Tidak teratur
S1/S2 tunggal : Ya Tidak
Nyeri dada : Ya Tidak
Bunyi jantung : Normal Murmur Gallop Lainnya__________
CRT : < 3detik 3 detik >3detik
Akral : Hangat Panas Dingin kering Dingin basah
Masalah __________________________________________________________________

PERSYARAFAN B3 (BRAIN), PENDENGARAN

GCS : Eye : Verbal : Motorik : Total :
Reflek Fisiologis: Patella Triceps Biceps Lain-lain ________________
Reflek patologis : Babinsky Budzinsky Kering Lain-lain __________
Lain-lain : _______________________________________________________
Istirahat/tidur : Jam/hari
Gangguan tidur : Ya Tidak Jelaskan ________________________
Masalah __________________________________________________________________

Penglihatan (Mata)
Pupil : Isokor Anisokor Lain-lain ______________________
Sklera : Ikterus Anemis Lain-lain ______________________
Gg. Penglihatan : Ya Tidak Jelaskan ________________________
Lain-lain : _______________________________________________________
Pendengaran (Telinga)
Kondisi telinga : Bersih Kotor
Gg. Pendengaran : Ya Tidak Jelaskan _______________________
Lain-lain : ______________________________________________________
Penciuman (Hidung)
Bentuk : Normal Tidak normal Jelaskan _________________
Gg. Penciuman : Ya Tidak Jelaskan _______________________
Lain-lain : ______________________________________________________
Masalah _________________________________________________________________

PERKEMIHAN B4 (BLADDER)
Kebersihan : Ya Tidak
Urine : __________CC/24 Jam Warna :__________ Bau :________
Alat bantu (Kateter, dll.) : Ya Tidak
Kandung kencing Membesar : Ya Tidak
Nyeri tekan : Ya Tidak
Gangguan : Anuria Oliguri Retensi Inkontinensia
Nokturia Lain-lain _________________________________
Masalah __________________________________________________________________

PENCERNAAN B5 (BOWEL)
Nafsu makan : Baik Menurun Frekuensi________________ x/hari
Porsi makan : Habis Tidak Jelaskan ______________________
Minum : ______________ CC/hari Jenis _________________________
Mulut dan tenggorokan
Mulut : Bersih Kotor Berbau
Mukosa : Lembab Kering Stomatitis
Tenggorokan : Nyeri menelan Kesulitan menelan
Pembesaran tonsil Lain-lain ___________________
Abdomen
Perut : Tegang Kembung Ascites
Nyeri tekan Lokasi ____________________________
Peristaltik : ______________ x/menit
Pembesaran lien : Ya Tidak
Pembesaran hepar : Ya Tidak
Buang Air Besar (BAB) :_____________ x/hari Teratur : Ya Tidak
Konsistensi ____________ Bau ___________ Warna ________
Lain-lain : _____________________________________________________
Masalah _________________________________________________________________

MUSKULOSKELETAL/INTEGUMEN B6 (BONE)
Kemampuan pergerakan bebas : Bebas Terbatas
Kekuatan otot : ________

Kulit
Warna kulit : Ikterus Slanotik Pucat Hiperpigmentasi
Turgor : Baik Cukup Kurang
Oedem : Ada Tidak Lokasi ___________________
Lain-lain : ______________________________________________________
Masalah __________________________________________________________________

ENDOKRIN
Tyroid membesar : Ya Tidak
Hiperpigmentasi : Ya Tidak
Hipoglikemi : Ya Tidak
Luka gangren : Ya Tidak
Lain-lain : ______________________________________________________
Masalah __________________________________________________________________

PERSONAL HYGIENE
Mandi : ______________ x/hari Memotong kuku : ____________ x/hari
Keramas : ______________ x/hari Ganti pakaian : ____________ x/hari
Sikat gigi : _________________ x/hari Lain-lain : __________ x/hari

DATA PENUNJANG
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TERAPI

No. Terapi Dosis Keterangan

DIAGNOSA KEPERAWATAN YANG MUNCUL

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Lamongan, __________________
Perawat yang mengkaji,

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