(… th)
I. PENGKAJIAN
A. Data
Demografi
1. Klien/Pasien
Tanggal pengkajian : ...................................
Tanggal masuk : ...................................
Ruangan : ...................................
Identitas
a. Nama : .......................................................................................
b. Tanggal lahir/umur : .........................................................................................
c. Jenis kelamin : ..........................................................................................
d. Agama : .........................................................................................
e. Suku : .........................................................................................
f. Diagnosa medis : .........................................................................................
g. Penanggung jawab : ..........................................................................................
2. Orang Tua/ Penanggung Jawab
a. Nama : ........................................................................................
b. Hubungan dengan klien : …………………………………………………………
c. Suku : ........................................................................................
d. Agama : ........................................................................................
e. Alamat : ........................................................................................
f. No. telepon : ........................................................................................
B. Riwayat Klien
1. Keluhan utama klien : ……………………………………………………….
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2. Riwayat penyakit klien sebelumnya :
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2. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) :
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Motorik kasar :
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Bahasa :
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Personal sosial :
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C. Riwayat Kesehatan Keluarga
1. Riwayat penyakit dalam keluarga:
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2. Genogram
Keterangan gambar :
: laki-laki : klien
: perempuan : meninggal
o. Diuresis :
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c. Vital sign
Capillary
Tanggal TD Nadi RR Suhu
refill
d. Kepala
Inspeksi
Palpasi
e. Mata
Inspeksi
Palpasi
f. Hidung
Inspeksi
Palpasi
g. Mulut
Inspeksi
Palpasi
h. Telinga
Inspeksi
Palpasi
i.Leher
Inspeksi
Palpasi
j. Paru-paru
Inspeksi
Palpasi
Perkusi
Auskultasi
k. Jantung
Inspeksi
Palpasi
Perkusi
Auskultasi
l. Abdomen
Inspeksi
Auskultasi
Perkusi
Palpasi
m. Genitalia
Inspeksi
n. Ekstremitas atas
Kanan Kiri
Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas