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FAKULTAS KESEHATAN
UNIVERSITAS TRIBHUWANA TUNGGADEWI - MALANG
A. PENGKAJIAN
1. Biodata Klien
a. Nama :
b. Umur :
c. Jenis kelamin :
d. Agama :
e. Suku / Bangsa :
f. Alamat :
g. No. Register :
h. Tanggal Masuk RS :
i. Tanggal Pengkajian :
j. Diagnosa Medis :
k. Nama Orang Tua :
1
5. Riwayat Imunisasi
GENOGRAM
b. Aspek Sosial
2
9. Pola Aktifitas-Latihan
Rumah Rumah Sakit
Makan/minum .................................................... ....................................................
Mandi .................................................... ....................................................
Berpakaian/berdandan .................................................... ....................................................
Toileting .................................................... ....................................................
Mobilitas di tempat tidur ....................................................
Berpindah .................................................... ....................................................
Berjalan .................................................... ....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu
orang lain, 4 = tidak mampu
BAK:
- Frekuensi/pola .................................................... .................................................
- Warna & Bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................
3
Kesulitan ................................................. .................................................
Pola Pertumbuhan dan Perkembangan
Tanda-tanda radang :
Funsi penglihatan : ( ) Baik ( ) Kabur
c. Hidung : Bentuk ………….. Warna …………. Pembengkakan …………
Nyeri tekan …….. Perdarahan …………..
d. Mulut dan Tenggorokan :
Warna bibir ……… Mukosa …………… Ulkus …………………...
Lesi ……………… Massa …………….. Warna Lidah ……………
Perdarahan gusi ………………………….
e. Telinga : Bentuk …………… Warna ……………. Lesi ……………………
Massa ……………. Nyeri …………………………………………..
f. Leher : Kekakuan………………..Nyeri/Nyeri tekan…………………………
Benjolan/massa Vena jugularis……………
3.Dada : Bentuk ………………… Pergerakan Dada ……………………
Nyeri/nyeri tekan ……… Massa …………. Peradangan ……
Jantung : Inspeksi
Perkusi
Auskultasi …………………………………………………..
Paru
: Inspeksi
Perkusi
Auskultasi …………………………………………………
4. Payudara dan Ketiak :
Benjolan/massa ……………….. Nyeri/nyeri tekan ……………..
Bengkak …………………………
5.Abdomen :
Inspeksi ……………………………………………………………….
Auskultasi …………………………………………………………….
Palpasi ………………………………………………………………..
Perkusi ……………………………………………………………….
6. Genetalia :
Inspeksi ………………………………………………………………
4
Palpasi ………………………………………………………………..
7. Ekstremitas : Kekuatan otot ………………………………………………………
Kontraktur …………………………… Pergerakan ……………….
Deformitas ……………………………Pembengkakan …………….
Nyeri/nyeri tekan ……………….
Pus/luka …………………………
Radiologi
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17. Kesimpulan
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Malang.
Pengkaji