Pengkajian Awal

PENGKAJIAN AWAL
A. Identitas Klien

1. Nama/nama panggilan:

2. Tempat tanggal lahir/usia:

3. Jenis kelamin:

4. A g a m a:

5. Pelaku rawat:

6. Alamat:

8. UPK/Dokter:

9. Diagnosis utama:

10. Diagnosis penyerta/metastase:

B. Identitas Orang Tua/Wali/Pelaku Rawat Lain

Pelaku Rawat Lain

Ibu Ayah Wali
(jika ada)

Nama: Nama: Nama: Nama:

U s i a: U s i a: U s i a: U s i a:

Pendidikan: Pendidikan: Pendidikan: Pendidikan:

Pekerjaan: Pekerjaan: Pekerjaan: Pekerjaan:

A g a m a: A g a m a: A g a m a: A g a m a:

Alamat: Alamat: Alamat: Alamat:

No telp: No telp: No telp: No telp:

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C. Identitas Saudara Kandung (jika pasien anak)

No Nama Usia Hubungan Kesehatan

D. Genogram

Keterangan:
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E. Riwayat Kesehatan

Riwayat:

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Obat-obatan sebelumnya:

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F. PENGKAJIAN FISIK

1. Keadaan umum:
2. Kesadaran:
3. Tanda–tanda vital:
a. Tekanan darah:
b. Denyut nadi:
c. Suhu:
d. Pernapasan:
4. Berat badan:
5. Tinggi badan:
6. Kepala:
7. Lingkar lengan:
8. Rambut & kepala:
Inspeksi:
Palpasi:
Catatan:
9. Mata dan penglihatan
Inspeksi:
Palpasi:
Catatan:
10. Hidung & sinus
Inspeksi:
Palpasi:
Catatan:
11. Telinga dan pendengaran
Inspeksi:
Palpasi:
Catatan:
12. Mulut dan tenggorokan
Inspeksi:
Palpasi:
Catatan:
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13. Sistem endokrin

Inspeksi:
Palpasi:
Catatan:
14. Thorax dan pernapasan
Inspeksi:
Palpasi:
Perkusi:
Auskultasi:
Catatan:
15. Abdomen
Inspeksi:
Auskultasi:
Perkusi:
Palpasi:
Catatan:
16. Genitalia dan anus
Inspeksi:
Palpasi:
Catatan:
17. Ekstremitas
Ekstremitas atas
Inspeksi:
Palpasi:
Catatan:
Ekstremitas bawah
Inspeksi:
Palpasi
Catatan:
18. Status neurologi
Inspeksi:
Palpasi:
Catatan:
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19. Sistem eliminasi

BAB
Konsistensi:
Frekuensi:
Keluhan:
BAK
Warna:
Frekuensi:
Keluhan:

G. Data Penunjang
Laboratorium
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Foto Rotgen, CT Scan, MRI, USG, EEG, ECG

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H. Terapi Saat Ini (ditulis dengan rinci)

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I. Kondisi Psikologis, Sosial, dan Spiritual

Psikologis (pasien dan keluarga)

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Sosial (pasien dan keluarga)

a. UPK:
b. LSM:
c. Jaminan kesehatan:
d. Penyokong dana:
e. Pendapatan perbulan:
f. Kondisi rumah:
g. Ventilasi rumah:
h. Rumah milik:
i. Keadaan lingkungan:
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Keterangan:
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Spiritual (pasien dan keluarga)

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J. Masalah Saat Ini

1. .....................................................................................................................................................................
2. .....................................................................................................................................................................
3. .....................................................................................................................................................................
4. .....................................................................................................................................................................

K. Tindakan saat Kunjungan

1. Fisik
Medis
a. .........................................................................................................................................................
b. ..........................................................................................................................................................
c. ..........................................................................................................................................................
Keperawatan
a. .........................................................................................................................................................
b. ..........................................................................................................................................................
c. ..........................................................................................................................................................
Fungsional
a. .........................................................................................................................................................
b. ..........................................................................................................................................................
c. ..........................................................................................................................................................
2. Psikologis
a. .........................................................................................................................................................
b. ..........................................................................................................................................................
c. ..........................................................................................................................................................
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3. Sosial
a. .........................................................................................................................................................
b. ..........................................................................................................................................................
c. ..........................................................................................................................................................
4. Spiritual
a. .........................................................................................................................................................
b. ..........................................................................................................................................................
c. ..........................................................................................................................................................

L. Tujuan Asuhan

Jangka panjang

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4. .............................................................................................................................................................
Jangka pendek

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M. Rencana Asuhan
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3. .............................................................................................................................................................
4. .............................................................................................................................................................

Hari dan tanggal pengkajian :

Waktu:

Perawat:

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Pengkajian Awal