A. PENGKAJIAN
1. Identitas
Identitas Pasien
1 Praktek Pre Klinik Tahun Ajaran 2017-2018
Nama : ____________________ No.Rek.Medis : ___________________
Umur : _____________________________________________________
Agama : _____________________________________________________
Pekerjaan : _____________________________________________________
Agama : _____________________________________________________
Alamat : _____________________________________________________
Nama : _____________________________________________________
Umur : _____________________________________________________
Pekerjaan : _____________________________________________________
Alamat : _____________________________________________________
2. Riwayat Kesehatan
a. Riwayat Kesehatan Sekarang
Keluhan utama (saat masuk rumah sakit dan saat ini)
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PENGGUNAAN :
4. POLA NUTRISI/METABOLISME
a. Pola Makan
Di rumah
Frekuensi :______________________________________________________________________
Di rumah sakit
NG tube : ( ) Tidak ( ) Ya
b. Pola Minum
Di rumah Di rumah sakit
Minuman : _______________________
disukai
5. POLA ELIMINASI
a. BAB
Di rumah Di rumah sakit
( ) lainnya, .............
b. BAK
Di rumah Di rumah sakit
c. Alat bantu : ( ) Tidak ada ( ) Kruk ( ) Pispot ditempat tidur ( ) Walker ( ) Tongkat
( ) kursi roda
Sebab, .........................................................
Vertigo: ( ) Ya ( ) Tidak
Deskripsi : P :.....................................................................................................................................
Q :....................................................................................................................................
S :....................................................................................................................................
T : ....................................................................................................................................
Penatalaksanaan nyeri:___________________________________________________________
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Lain-lain: __________________________________________________________________
Jelaskan : ........................................................................................................................................
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b. Role/peran
( ) overload peran ( ) perubahan peran ( ) transisi peran karena sakit
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c. Identity/identitas diri
( ) kurang percaya diri ( ) merasa kurang memiliki potensi
Jelaskan : ........................................................................................................................................
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Jelaskan : .......................................................................................................................................
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Jelaskan : ........................................................................................................................................
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Tinggi badan
LILA
Kepala :
Rambut
Mata
Hidung
Mulut
Telinga
Leher
Trakea
JVP
Tiroid
Nodus Limfe
Dada I
Paru P
Abdomen I
Muskuloskeletal/Sendi Inspeksi
Palpasi
Vaskular Perifer
Integumen Inspeksi
Palpasi
Neurologi
Status mental/GCS
Saraf cranial
Reflek fisiologi
Reflek patologis
Payudara
Genitalia
Rectal
Laboratorium
16. TERAPI
PERENCANAAN PEMULANGAN
NAMA MAHASISWA :
NIM :
TEMPAT PRAKTEK :
TGL PRAKTEK :
TGL PENGKAJIAN :
I. IDENTITAS DATA
Nama anak :
Tempat/Tgl Lhr :
Umur :
Jenis Kelamin :
Pendidikan :
Anak ke- :
BB/TB :
Alamat :
Nama Ibu : Nama Ayah :
Umur : Umur :
Pekerjaan : Pekerjaan :
Pendidikan : Pendidikan :
Alamat : Alamat :
DX. MEDIS :
No. RM :
TGL Masuk RS :
VIII. IMUNISASI
Usia Pemberian Usia Pemberian Usia Pemberian
Jenis Imunisasi
I II III
BCG
HEPATITIS
DPT
POLIO
CAMPAK
X. PEMERIKSAAN FISIK
a. Keadaan Umum Klien
b. TB / BB
c. Kepala (Lingkar Kepala, Rambut, Kebersihan, Warna, Tekstur)
XIII. PENATALAKSANAAN
Terapi yang didapatkan saat dirawat / sekarang ditulis dengan rinci