No.

RM :
Nama :
Jenis Kelamin :
Tanggal Lahir :
(Mohon diisi atau tempelkan stiker)
RAWAT INAP

ASESMEN KEPERAWATAN
(dilengkapi dalam waktu 2 jam pertama pasien masuk ruang rawat inap)
Tanggal Masuk Pukul : Unit Kerja :
PEMERIKSAAN FISIK

1. Kesadaran :
 Compos Mentis  Somnolen
 Sopor  Koma
TD : ______ mmHg N : ______ x/menit RR : ______ x/menit S : ______ °C

2. Gastrointestinal :
Keluhan  Tidak  Ya. Jika ya, Sebutkan ........................................................................................................................................................
 Pembatasan makanan, sebutkan ........................................................................................................................................................................
Gigi palsu  Ya, gigi atas / gigi bawah (lingkari salah satu / keduanya)  Tidak
Mual  Ya,  Tidak
Muntah  Ya,  Tidak BB : ................... Kg TB : ................... Cm Lingkar Kepala Anak : ................... Cm

3. Neurosensori :
a. Pendengaran :  Normal  Tidak Normal, Sebutkan .....................................................................................................................
b. Penglihatan : OD OD
Visus .............................................. ..............................................
Pergerakan .............................................. ..............................................
Alis Mata .............................................. ..............................................
Palpebra Superior .............................................. ..............................................
Palpebra Inferior .............................................. ..............................................
Kornea .............................................. ..............................................
Iris .............................................. ..............................................
Konjungtiva Bulbi .............................................. ..............................................
Sekret .............................................. ..............................................
Tekanan Bola Mata
Pupil - Reflek .............................................. ..............................................
- Ukuran .............................................. ..............................................
- Isokor .............................................. ..............................................
Bilik Mata Depan
- Hifema .............................................. ..............................................
- Hipopion .............................................. ..............................................
Lensa .............................................. ..............................................

4. Eliminasi :
a. Defekasi  Normal  Tidak Normal, Sebutkan ...........................................................................................................................
b. Miksi  Normal  Tidak Normal, Sebutkan ...........................................................................................................................

5. Obstetri dan Ginekologi (khusus untuk pasien wanita) :

Hamil :  Ya  Tidak HPHT : Keluhan Menstruasi : ..........................................................................................

6. Kulit & Kelamin

a. Keadaan Kulit  Normal  Tidak Normal, Sebutkan .................................................................................................................................
b. Urogenitalia  Normal  Tidak Normal, Sebutkan .................................................................................................................................

Rumah Sakit Khusus Mata Medan Baru RM.5B /Rev.01/2013