Kajian Data Dasar
Kajian Data Dasar
I. IDENTITAS
1. Nama : ………………………………………………….
2. Umur : ………………………………………………….
3. Jenis Kelamin : ………………………………………………….
4. Agama : ………………………………………………….
5. Suku / Bangsa : ………………………………………………….
6. Bahasa : ………………………………………………….
7. Pendidikan : ………………………………………………….
8. Pekerjaan : ………………………………………………….
9. Alamat : ………………………………………………….
10. Alamat yg mudah dihubungi : ………………………………………………….
11. Ditanggung oleh : Askes / Astek / Jamsostek / JPS / Sendiri
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3. Riwayat Kesehatan Yang Lalu :
…………………………………………………………………………………….
…………………………………………………………………………………….
…………………………………………………………………………………….
4. Riwayat Kesehatan Keluarga :
…………………………………………………………………………………….
…………………………………………………………………………………….
…………………………………………………………………………………….
III. POLA AKTIFITAS SEHARI-HARI
B. Pola Eliminasi
1. B A B
- Warna ………………………………… ……………………………
- Bau ………………………………… ……………………………
- Konsistensi ………………………………… ……………………………
- Jumlah ………………………………… ……………………………
- Frekwensi ………………………………… ……………………………
- Masalah BAB ………………………………… ……………………………
- Upaya mengatasi ………………………………… ……………………………
2. B A K
- Sepontan /alat bantu …………………………………. ………….............................
- Warna …………...................................... .............................................
- Bau ...................................................... .............................................
- Konsistensi ...................................................... .............................................
- Jumlah ...................................................... .............................................
- Frekwensi ...................................................... .............................................
- Masalah BAK ...................................................... .............................................
- Upaya mengatasi …………………………………. ……………………………
F. Kebiasaan
- Merokok ...................................................... .............................................
- Alkohol ...................................................... .............................................
- Jamu, dll ...................................................... .............................................
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V. KONSEP DIRI
A. Gambaran Diri
.............................................................................................................................................
B. Harga Diri
.............................................................................................................................................
C. Ideal Diri
.............................................................................................................................................
D. Identitas Diri
.............................................................................................................................................
E. Peran
.............................................................................................................................................
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G. Pemeriksaan Abdomen
a. Inspeksi
- Bentuk abdomen : ………………………………………………….............
- Benjolan / Massa : ………………………………………………….............
- Bayangan pembuluh darah pada abdomen
…………………………………………………………………………..............
- Luka : post laparotomi / post SC : ket luka…………………
b. Auskultasi
- Peristaltik Usus : …………………………………………………
c. Palpasi
- Tanda nyeri tekan : …………………………………………………
- Benjolan / massa : …………………………………………………
- Tanda-tanda ascites : …………………………………………………
- Hepar : …………………………………………………
- Lien : …………………………………………………
- Titik Mc. Burne : …………………………………………………
d. Perkusi
- Suara Abdomen
………………………………………………………………………….............…...
- Pemeriksaan Ascites
…………………………………………………………………………….................
J. Pemeriksaan Neurologi
1. Tingkat kesadaran ( secara kuantitatif ) / GCS :
………………………………………………………………………………..
2. Tanda – tanda rangsangan otak ( meningeal sign ) :
………………………………………………………………………………..
3. Syaraf otak( Nervus cranialis ) :
………………………………………………………………………………..
4. Fungsi Motorik :
………………………………………………………………………………..
5. Fungsi Sensorik :
………………………………………………………………………………..
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6. Refleks :
a. Refleks Fisiologis
……………………………………………………………………………
b. Refleks Patologis
……………………………………………………………………………
PEMERIKSAAN PENUNJANG
A. Diagnosa Medis : …………………………………………………………………
B. Pemeriksaan Diagnostik / Penunjang Medis :
1. Laboratorium
……………………………………………………………………………………………
……………………………………………………………………………………………
2. Rontgen
……………………………………………………………………………………………
……………………………………………………………………………………………
3. E C G
……………………………………………………………………………………………
……………………………………………………………………………………………
4. U S G
……………………………………………………………………………………………
……………………………………………………………………………………………
5. Lain – lain
……………………………………………………………………………………………
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Mahasiswa
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NIM.