Nama Mahasiswa : RS :
NIM : Ruangan :
Tanggal Pengkajian : Jam :
A. IDENTITAS PASIEN
Nama : __________________________
Umur : __________________________
Tanggal Lahir : __________________________
Jenis Kelamin : __________________________
Berat Badan : __________________________
Panjang Badan : __________________________
C. KELUHAN UTAMA
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Natal
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Postnatal
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
H. RIWAYAT SOSIAL
1. Pengasuh anak
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Hubungan dengan anggota keluarga
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Hubungan dengan teman sebaya
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Pembawaan umum
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Pola minum
Sebelum Sakit Saat Sakit
Frekuensi
Jenis
Jumlah (cc/botol)
Yang disukai
Yang tidak disukai
Pantangan/Alergi
Gangguan
3. Istirahat tidur
Sebelum sakit Saat sakit
Tidur siang
Tidur malam
Gangguan
4. Eliminasi
Sebelum sakit Saat sakit
BAK
BAB
Gangguan
5. Personal hygiene
Sebelum sakit Saat sakit
Mandi
Sikat gigi
Ganti pakaian
Memotong kuku
Lain-lain
K. PEMERIKSAAN FISIK
1. Keadaan umum
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Tanda vital
Nadi : ____________ kali/menit
RR : ____________ kali/menit
Suhu : ____________ °C
3. Antopometri
BB : ____________ kg TB : _____________ cm
4. Kepala dan leher
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Integumen
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. Thoraks (Pulmo & Cor)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. Abdomen
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
7. Genitalia
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
8. Neuro – Muskuloskeletal
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
M. PEMERIKSAAN PENUNJANG
1. Laboratorium
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Rontgen
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. USG
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
N. TERAPI MEDIS
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________