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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
KEBUTUHAN ISTIRAHAT TIDUR

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-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 dan kebersihan diri
Keterangan Sebelum Sakit Saat Sakit
Mobilitas Rutin
Waktu Senggang
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
No Keterangan Sebelum Sakit Saat Sakit
1 Jam berangkat tidur .............................. ..............................
malam

2 Waktu yang diperlukan .............................. ..............................


untuk dapat tidur

3 Jam tidur malam (lama) .............................. ..............................

4 Jam tidur siang (lama) .............................. ..............................

5 Kebiasaan menjelang .............................. ..............................


tidur

6 Jumlah terjaga saat tidur .............................. ..............................

7 Obat-obatan yang
digunakan untuk tidur .............................. ..............................

8 Gangguan Tidur .................................... ...............................

9 Perasaan waktu bangun ................................... ................................

Deskripsi lengkap tentang gangguan tidur yang sedang dialami :


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

f. 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…………………………………………………………………………………..
……………………………………………………………………………………………………..
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…………………………