PENGKAJIAN DATA DASAR DAN FOKUS

Pengkajian Diambil tanggal : _____________________________________ Jam: _____________

Tanggal masuk : _____________________________________ Reg: _____________
No Kamar : _______________________________________________________
Diagnosa Masuk : _______________________________________________________

I. IDENTENTITAS
1. Nama : _______________________________________________________
2. Umur : _______________________________________________________
3. Jenis kelamin : _______________________________________________________
4. Agama : _______________________________________________________
5. Suku/Bangsa : _______________________________________________________
6. Bahasa : _______________________________________________________
7. Pendidikan : _______________________________________________________
8. Pekerjaan : _______________________________________________________
9. Alamat/No. Telp : _______________________________________________________
10. Penanggung jawab : _______________________________________________________

II. RIWAYAT SEBELUM SAKIT

1. Penyakit berat yang pernah diderita:
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2. Obat-obatan yang biasa dikonsumsi:
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3. Kebiasaan berobat:
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4. Alergi obat/makanan:
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5. Alat bantu yang digunakan:
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III. RIWAYAT PENYAKIT SEKARANG

1. Keluhan utama:
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2. Tanggal mulai sakit:
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3. Proses terjadinya sakit:
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_
Tiba-tiba Berangsur-angsur
 Faktor pencetus:
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4. Upaya yang telah dilakukan:
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5. Tanda-tanda vital:
S: _______ oC N: ______ x/menit RR: ______ x/menit T: ________ mm/Hg

IV. RIWAYAT KESEHATAN KELUARGA

1. Penyakit yang pernah diderita oleh anggota keluarga:
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2. Penyakit yang sedang diderita oleh anggota keluarga:
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V. PENGKAJIAN SISTEM
1. Sistem Pernafasan (B1= Breathing)
Data Subjektif: ________________________________________________________________
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Data Objektif: ________________________________________________________________
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2. Sitem Kardiovaskuler (B2= Blood)
Data Subjektif: ________________________________________________________________
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Data Objektif: ________________________________________________________________
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3. Sistem Neurologi (B3= Brain)
Data Subjektif: ________________________________________________________________
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Data Objektif: ________________________________________________________________
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4. Sistem Perkemihan (B4: Bladder)
Data Subjektif: ________________________________________________________________
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Data Objektif: ________________________________________________________________
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 5. Sistem Pencernaan (B5: Bowel)
Data Subjektif: ________________________________________________________________
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Data Objektif: ________________________________________________________________
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6. Sistem Muskuloskleletal (B6: Bone)
Data Subjektif: _______________________________________________________________-
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Data Objektif: ________________________________________________________________
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7. Sistem lain yang terkait (Sistem Endokrin. Reproduksi, Imunologi, dsb)
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8. Pola istirahat:
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9. Pola personal higyene:
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VI. PSIKOSOSIAL
1. Sosial/Interaksi:
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2. Konsep diri:
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3. Spiritual:
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VII. TINDAKAN MEDIS DAN OAT-OBATAN YANG DIBERIKAN

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VIII. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Radiologi
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3. Informasi lain-lain
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Perawat

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