KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN JAMBI

JURUSAN KEPERAWATAN
JL. Dr. Tazar No.05 Buluran Kenali Telanaipura Jambi Telp (0741)65816

FORMAT PENGKAJIAN KEPERAWATAN

Tanggal/ jam masuk RS : .......................................................

Ruang : ........................................................
No. Register : .......................................................
Diagnosa Medis : .......................................................
Tanggal Pengkajian : .......................................................

IDENTITAS KLIEN
Nama : ............................................ Suami/Isteri/Ortu :
Umur : ............................................ Nama : ......................................
Jenis Kelamin : ............................................ Pekerjaan : ......................................
Agama : ............................................ Alamat : ......................................
Suku/ bangsa : ............................................ ......................................
Bahasa : ............................................ Penanggung : ......................................
Jawab
Pendidikan : ............................................ Nama : ......................................
Pekerjaan : ............................................ Alamat : ......................................
Status : ............................................ ......................................
Alamat : ............................................
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KELUHAN UTAMA
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RIWAYAT PENYAKIT SEKARANG

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Upaya yang telah dilakukan : ....................................................................................................................
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Terapi yang telah diberikan : .....................................................................................................................
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RIWAYAT KESEHATAN DAHULU

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RIWAYAT KESEHATAN KELUARGA
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Genogram :

KEADAAN LINGKUNGAN YANG MEMPENGARUHI TIMBULNYA PENYAKIT

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POLA FUNGSI KESEHATAN

1. Pola persepsi dan tata laksana kesehatan
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2. Pola nutrisi dan metabolisme

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3. Pola eliminasi
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4. Pola aktivitas
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5. Pola istirahat tidur

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6. Pola kognitif dan persepsi sensori

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7. Pola konsep diri
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8. Pola hubungan peran

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9. Pola fungsi seksual-seksualitas

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10. Pola mekanisme koping

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11. Pola nilai dan kepercayaan

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PEMERIKSAAN FISIK
1. Status kesehatan umum
Keadaan/ penampilan umum :
Kesadaran : ................................................. GCS : ......................................
BB sebelum sakit : ................................................. TB : ......................................
BB saat ini : .................................................
BB ideal : .................................................
Perkembangan BB : .................................................
Status gizi : .................................................
Status Hidrasi : .................................................

Tanda-tanda vital :
TD : ............... mmHg Suhu : .................. 0C
N : ............... x/mnt RR : .................. x/mnt

2. Kepala
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3. Leher
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4. Thorak (dada)
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5. Abdomen
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6. Tulang belakang
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7. Ekstremitas
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8. Genitalia dan anus

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9. Pemriksaan neurologis
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PEMERIKSAAN DIAGNOSTIK
1. Laboratorium
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2. Radiologi
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3. Lain-lain
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TERAPI
1. Oral
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2. Parenteral
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3. Lain-lain
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Jambi, ................................................
Mahasiswa

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NIM. ..................................................