PEMERIKSAAN PARAF

I. PEMERIKSAAN
Keluhan Utama : ............................................................................................
Riwayat Penyakit Sekarang : ..............................................................................................
...........................................................................................
..........................................................................................
Riwayat Penyakit Dahulu : ............................................................................................
Riwayat Pemyakit Keluarga : ........................................................................................

II. PEMERIKSAAN FISIK

VI. Rencana Teraphi
Keadaan Umum : Compos Mentis / Somnolen
Tanda Vital
TD :.................mmHg Nadi : .........x/menit
RR :...........x/menit Suhu : .........oC
TB :..............cm BB : ...............kg
Kepala
Mata : Conjtiva Anemis ( ) (..............................................)
Hidung : Discharge ( ) (..........................................................)
Mulut/Tenggorokan : stomatitis ( ), Hyeperemia ( ) T....T.....
Thorax
Inspeksi : simetris / asimetris Jantung : Regular / Iregular
Palpasi : Nyeri tekan ( ) (....................................................)
Perkusi : Sonor / hypersonor (..............................................)
Auskulatsi : Ronkhi basah / ronkhi kering / whezing/ .................
Abdomen VII. Asuhan Keperawatan
S:
Inspeksi : simetris / asimetris / ascites /
Palpasi : nyeri tekan ( ) Perkusi : tymphani / Pekak
Auskultasi : Peristaltik usus Normal / Meningkat / Melemah
O:
Urugenital : tidak dilakukan pemeriksaan ( .............................)
.............................................................................
Extrimitas – Superior : Kuat Angkat (+/+) (+/-) (-/-) A:
- Inferior : Kuat Angkat (+/+) (+/-) (-/-)
III. Rencana Penunjang Diagnostik
Laboratorium : GDS ( ), GDP ( ), PP ( ) P:
Au ( ) Cls ( ) Tg ( ) Hb ( )
Rontgen :...........................................
EKG : ............................................ I :
IV. DIAGNOSA DAN Dx Deferential
E:
V. RUJUK
Rumah Sakit :....................
Poli :.....................
 PEMERIKSAAN PARAF
VIII. PEMERIKSAAN
Keluhan Utama : ............................................................................................
Riwayat Penyakit Sekarang : ..............................................................................................
...........................................................................................
..........................................................................................
Riwayat Penyakit Dahulu : ............................................................................................
Riwayat Pemyakit Keluarga : ........................................................................................

IX. PEMERIKSAAN FISIK

XIII. Rencana Teraphi
Keadaan Umum : Compos Mentis / Somnolen
Tanda Vital
TD :.................mmHg Nadi : .........x/menit
RR :...........x/menit Suhu : .........oC
TB :..............cm BB : ...............kg
Kepala
Mata : Conjtiva Anemis ( ) (..............................................)
Hidung : Discharge ( ) (..........................................................)
Mulut/Tenggorokan : stomatitis ( ), Hyeperemia ( ) T....T.....
Thorax
Inspeksi : simetris / asimetris Jantung : Regular / Iregular
Palpasi : Nyeri tekan ( ) (....................................................)
Perkusi : Sonor / hypersonor (..............................................)
Auskulatsi : Ronkhi basah / ronkhi kering / whezing/ .................
Abdomen
XIV. Asuhan Keperawatan
Inspeksi : simetris / asimetris / ascites / S:
Palpasi : nyeri tekan ( ) Perkusi : tymphani / Pekak
Auskultasi : Peristaltik usus Normal / Meningkat / Melemah
Urugenital : tidak dilakukan pemeriksaan ( .............................) O:
.............................................................................
Extrimitas – Superior : Kuat Angkat (+/+) (+/-) (-/-)
- Inferior : Kuat Angkat (+/+) (+/-) (-/-) A:
X. Rencana Penunjang Diagnostik
Laboratorium : GDS ( ), GDP ( ), PP ( )
P:
Au ( ) Cls ( ) Tg ( ) Hb ( )
Rontgen :...........................................
EKG : ............................................ I :
XI. DIAGNOSA DAN Dx Deferential

E:
XII. RUJUK
Rumah Sakit :....................
Poli :.....................