B. RIWAYAT PENYAKIT
Keluhan utama saat masuk RS:
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Riwayat Penyakit Sekarang:
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Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan,
mulai dari pasien MRS (UGD/POLI), sampai diambil kasus kelolaan.
Masalah atau Dx Medis pada saat MRS:
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C. PENGKAJIAN KEPERAWATAN
1. Persepsi dan pemeliharaan kesehatan (Pengetahuan tentang penyakit/ perawatan; obat
yang biasa dikonsumsi, faktor risiko tentang penyakit, seperti: riwayat keluarga,
kebiasaan, dll.; perlindungan kesehatan; kebiasaan dalam menangani sakit, seperti:
pilihan pengobatan; kebutuhan akan edukasi kesehatan/ discharge planning)
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2. Pola Nutrisi/Metabolik
Program diit RS : ______________________________________________________
Intake makanan (Pengkajiam nutrisi ABCD/ skrining nutrisi; faktor spesifik dalam
memilih makanan, seperti: budaya, agama, ekonomi; faktor yang mempengaruhi
ingesti makanan, seperti: nafsu makan, kenyamanan, kesehatan gigi dan mulut, alergi,
nyeri, mual, muntah, pantangan makanan): __________________________________
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Intake cairan : ______________________________________________________
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3. Pola Eliminasi
a. Buang Air Besar (frekuensi, warna, jumlah, konsistensi, ketidaknyamanan,
kontrol saat defekasi, apakah ada perubahan khusus)
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b. Buang Air Kecil (frekuensi, warna, jumlah, bau, ketidaknyamanan, kontrol saat
defekasi, apakah ada perubahan khusus, nokturia)
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c. Balance Cairan
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6. Pola Perceptual (penglihatan; pendengaran; pengecap; sensasi; pembau; penggunaan
alat bantu; nyeri dan kenyamanan):
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7. Pola persepsi diri (pandangan klien tentang sakitnya; kecemasan; konsep diri):
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8. Pola Seksualitas dan Reproduksi (masalah seksual; fertilitas, libido, menstruasi,
kontrasepsi, dll.):
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10. Pola Managemen Koping-Stress (stress saat ini; koping; perubahan terbesar dalam
hidup pada akhir-akhir ini/ kehilangan, dll):
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11. Sistem Nilai dan Keyakinan (budaya terkait kesehatan; pandangan klien tentang
agama; kegiatan agama, dll.):
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D. PEMERIKSAAN FISIK
(Chepalocaudal)
Keluhan yang dirasakan saat ini: _____________________________________________
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Kesadaran:
Keadaan umum :
TD : ____________ mmHg
P : ____________ x/menit
N : ____________ x/menit
S : ____________ OC
BB/ TB: _________ kg/ __________ cm
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Kepala:
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Leher:
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Thorak:
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Abdomen:
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Inguinal:
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Ekstremitas:
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E. PENANGANAN KASUS (dimulai saat Anda mengambil sebagai kasus kelolaan,
sampai akhir praktik)
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