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U N I V E R S I T A S B O N D O W O S O

PR OGR A M S TUD I D III K E P ER AWATA N


Jalan Chairil Anwar No.3B Tlp/Fax. (0332) 433015 Bondowoso

FORMAT PENGKAJIAN
PERSONAL HYGIENE

Rumah sakit :………………………………………………………………………………..


Ruangan :………………………………………………………………………………..
Tgl/Jam MRS :………………………………………………………………………………..
Dx. Medis :………………………………………………………………………………..
No. Register :………………………………………………………………………………..

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


Tgl/Jam pengkajian :..............................................................................................................

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 :
a. Saat MRS
.........................................................................................................................................
.........................................................................................................................................
b. Saat Pengkajian
.........................................................................................................................................
.........................................................................................................................................
2. Riwayat Penyakit Sekarang :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
3. Riwayat Penyakit Dahulu :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
4. Riwayat Penyakit Keluarga :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
5. Genogram :
Ket :...........................................

III. POLA FUNGSI KESEHATAN :


a. Pola Persepsi dan Tata Laksana Kesehatan
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
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
Keterangan Sebelum Sakit Saat Sakit
Mobilitas Rutin
Waktu Senggang
Mobilitas di atas tempat tidur
Berdiri-Berjalan
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 Kebersihan Diri


Keterangan Sebelum Sakit Saat Sakit
Mandi
Menyikat gigi
Berhias
Menyisir rambut
Merawat rambut
Berpakaian
Toileting
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total

Deskriptif lengkap gangguan pada pola kebersihan diri


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

g. Pola Kognitif dan Persepsi Sensori


........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
IV. PEMERIKSAAN FISIK
1. Keadaan Umum :............................................................................................................
Kesadaran :.....................................................................................................................
Suhu :...............................oC TB :................................cm
RR :...............................x/mnt BB saat ini :..........................Kg
TD :...............................mmHg BB Ideal :...........................Kg
Nadi :...............................x/mnt
2. Kepala dan Leher
 Rambut : ……………………………………………………………………………….....
 Wajah : ……………………………………………………………………………….....
 Mata : ……………………………………………………………………………….....
 Hidung : ……………………………………………………………………………….....
 Mulut : ……………………………………………………………………………….....
 Gigi : ……………………………………………………………………………….....
 Telinga : ……………………………………………………………………………….....

3. Leher
I.............................................................................................................................................
P...........................................................................................................................................

4. Payudara dan Ketiak


I.............................................................................................................................................
P...........................................................................................................................................

5. Dada
Paru-Paru
I……………………………………………………………………………………………………
P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….
Jantung
I……………………………………………………………………………………………………
P.......................................................................................................................................
P.......................................................................................................................................
A………………………………………………………………………………………………….

6. Abdomen
I………………………………………………………………………………………………………
A…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….

7. Ekstremitas
Atas
I…………………………………………………………………………………………………….
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………i
……………………………………………………………………………………………………...
Kekuatan Otot……………………………………………………………………………………
Bawah
I…………………………………………………………………………………………………….
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………
……………………………………………………………………………………………………..
Kekuatan Otot……………………………………………………………………………………

8. Tulang Belakang/ Punggung-pinggang


I …………………………………………………………………………………………………….
P……………………………………………………………………………………………………

9. Anus – Genetalia
…………………………………………………………………………………………………….
……………………………………………………………………………………………………..
10. Pemeriksaan Neurologis
Kesadaran……………………………………………………………………………………….
Meningeal Sign…………………………………………………………………………………
Refleks
 Fisiologis………………………………………………………………………………….
 Patologis…………………………………………………………………………………
Pemeriksaan Saraf Kranial (I-XII)
……………………………………………………………………………………………………..
………………………………………………………………………………………………………………......
………………………………………………………………………………………………………………......
………………………………………………………………………………………………………………......
………………………………………………………………………………………………………………......
…………………………………………………………………………………………………………………..

V. Pemeriksaan diagnostik (cantumkan tanggal pemeriksaan)


.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

VI. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)


.....................................................................................................................................................
.....................................................................................................................................................
....................................................................................................................................................

VII. Terapi (disertai dosis tiap pemberian)


Oral
.....................................................................................................................................................
.....................................................................................................................................................
Parenteral
.....................................................................................................................................................
.....................................................................................................................................................

………………,…………………..20…..
Mahasiswa

( )
NIM…………………………