SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

dr. SOEBANDI JEMBER

Program Studi:
● S.1 Keperawatan ● Profesi Ners ● D.III Kebidanan ●S1 Farmasi
Jl. dr Soebandi No. 99Jember, Telp/Fax. (0331) 483536,
E_mail:jstikesdr.soebandi@yahoo.com

FORMAT PENGKAJIAN

Klinik :………………………………………………………………………………..
Tgl/Jam Berkunjung :………………………………………………………………………………..
No. Register :………………………………………………………………………………..

Pengkajian Oleh :..............................................................................................................

I. BIODATA PENANGGUNG JAWAB

Nama Klien Nama :……………………........
:..............................................................................................................
Umur Umur :………………………….
:..............................................................................................................
Jenis Kelamin Pendidikan :………………………….
:..............................................................................................................
Pendidikan Pekerjaan :………………………….
:..............................................................................................................
Pekerjaan Alamat :………………………….
:..............................................................................................................
Agama Hubungan dengan klien
:..............................................................................................................
Gol. Darah Suami/ Istri/Orangtua/…………………..
:..............................................................................................................
Alamat :..............................................................................................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama :
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Dahulu :
...............................................................................................................................................
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Trauma masa lalu/ fraktur.....................................................................................................
Pembedahan..........................................................................................................................
4. Riwayat Penyakit Keluarga :
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...............................................................................................................................................
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 5. Genogram :
Ket :.....................................................

III. POLA FUNGSI KESEHATAN :

a. Pola Persepsi dan Tata Laksana Kesehatan
........................................................................................................................................
........................................................................................................................................
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b. Pola Nutrisi
Macam Sebelum Sakit Saat sakit
Makan
 Frekuensi ............................... ................................
 Jenis ............................... ................................
 Porsi ............................... ................................
 Keluhan ............................... ................................

Minum
 Frekuensi ............................... ................................
 Jenis ............................... ................................
 Jumlah ............................... ................................
 Keluhan ............................... .................................

c. Pola Eliminasi
Kebiasaan BAB
Keterangan Sebelum Sakit Saat Sakit

 Frekuensi ....................................... .......................................

 Jumlah ....................................... .......................................
 Bau ....................................... .......................................
 Warna ....................................... .......................................
 Konsistensi ....................................... .......................................
....................................... .......................................
 Keluhan

Kebiasaan BAK
Keterangan Sebelum Sakit Saat Sakit

 Frekuensi ....................................... .......................................

 Jumlah ....................................... .......................................
 Bau ....................................... .......................................
 Warna ....................................... .......................................
 Keluhan ....................................... .......................................

d. Pola Aktivitas dan kebersihan diri

 Keterangan Sebelum Sakit Saat Sakit
Mobilitas Rutin
Mobilitas di atas tempat tidur
Waktu Senggang
Berdiri-berjalan
Mandi
Berpakaian
Berhias
Toileting
Makan-minum
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total

e. Pola Istirahat-Tidur
Keterangan Sebelum Sakit Saat Sakit
Lama tidur siang
Lama tidur malam
Pengantar tidur
Gangguan tidur

f. Pola Kognitif dan Persepsi Sensori

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IV. PEMERIKSAAN FISIK

1. Keadaan
Umum :............................................................................................................
Kesadaran :.....................................................................................................................
No Tanda-Tanda Vital Hasil

1 Tekanan Darah ......................................................................................

2 Nadi ......................................................................................

3 RR ......................................................................................

4 Suhu ......................................................................................

TB :................................cm
BB saat ini :................................Kg
BB Ideal :.................................Kg

2. Kepala
 Rambut :………………………………………………………………………….......
 Wajah : ……………………………………………………………………….........
 Mata : ……………………………………………………………………….........
 Hidung :………………………………………………………………………….......
 Mulut :………………………………………………………………………….......
  Gigi :………………………………………………………………………….......
 Telinga :………………………………………………………………………….....

3. Leher
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4. Payudara dan Ketiak

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.
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5. Dada
Paru-Paru
.……………………………………………………………………………………………………
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.…………………………………………………………………………………………………...
Jantung
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6. Abdomen
.…………………………………………………………………………………………………..
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.…………………………………………………………………………………………………
.………………………………………………………………………………………………….

7. Ekstremitas
Atas
.…………………………………………………………………………………………………..
.………………………………………………………………………………………………….
Gerakan Sendi…………………………………………………………………………………
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Kekuatan Otot…………………………………………………………………………………

Bawah
.………………………………………………………………………………………………….
.…………………………………………………………………………………………………
Gerakan Sendi………………………………………………………………………………..
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Kekuatan Otot…………………………………………………………………………………

8. Tulang Belakang/ Punggung-pinggang

. ……………………………………………………………………………………………………
.…………………………………………………………………………………………………..

9. Anus – Genetalia
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10. Pemeriksaan Neurologis

Kesadaran………………………………………………………………………………………
Meningeal Sign…………………………………………………………………………………
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V. Pemeriksaan diagnostik (cantumkan tanggal pemeriksaan)
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VI. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)

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VII. Terapi (disertai dosis tiap pemberian)

Oral
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Parenteral
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………………,…………………..20…..
Mahasiswa

( )
NIM…………………………
 ANALISA DATA
Nama pasien :
No. RM :
DATA ETIOLOGI MASALAH
 DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN PRIORITAS

NO PRIORITAS DIAGNOSA KEPERAWATAN

1.

2.

3.

4.
 INTERVENSI KEPERAWATAN

DIAGNOSA KEPERAWATAN NOC DAN INDIKATOR

URAIAN AKTIVITAS RENCANA NAMA DAN TTD
NO TANGGAL DITEGAKKAN / KODE SERTA SKOR AWAL DAN SKOR
TINDAKAN (NIC) PERAWAT
DIAGNOSA KEPERAWATAN TARGET
 IMPLEMENTASI & EVALUASI KEPERAWATAN
EVALUASI
DIAGNOSA KEPERAWATAN
(PERBANDINGAN SKOR AKHIR
NO DITEGAKKAN /KODE IMPLEMENTASI NAMA DAN TTD
TERHADAP SKOR AWAL DAN SKOR
DIAGNOSA KEPERAWATAN PERAWAT
TARGET)