FORMAT PENGKAJIAN KEPERAWATAN

AKADEMI KEPERAWATAN JABAL GHAFUR SIGLI

Nama Mahasiswa :

NI M :

1. IDENTITAS PASIEN`
Nama Pasien :
Umur :
Jenis Kelamin :
Suku :
Agama :
Pekerjaan :
Pendidikan :
Tanggal Masuk :
Alamat :
Diagnosa Medik :

2. RIWAYAT PENYAKIT
a. Keluhan Utama
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

b. Riwayat Penyakit Sekarang

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

c. Riwayat Penyakit Yang Lalu

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

d. Riwayat Penyakit Keluarga

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

3. Pola Kebiasaan Sehari – Hari ( Sebelum dan Selama Sakit )

a. Pola makan / minum
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

b. Pola istirahat / tidur

 .............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

c. Pola eliminasi
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

d. Pola aktivitas
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

4. Data Psikologi
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

5. Data Social
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

6. Data Spiritual
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

7. Patofisiologi Diagnosa Medik

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………………………………………………………....

8. Pemeriksaan Fisik
Keadaan Umum : Denyut Nadi :
Tingkat Kesadaran : Tekanan Darah :
 Tinggi Badan : Pernafasan :
Berat Badan : Temperatur :

Lain – Lain : ( Head To Toe ) dengan cara inspeksi, palpasi, perkusi dan auskultasi

9. Pemeriksaan Penunjang

10. Therapi

ANALISA DATA
NO DATA ETIOLOGI MASALAH
 ( Dapat dibuat lembaran lanjutannya pada kertas lain )

FORMAT PENGKAJIAN KEPERAWATAN PADA HARI UJIAN

AKADEMI KEPERAWATAN JABAL GHAFUR SIGLI

1. Keluhan Utama
2. Data Fokus ( sesuai keluhan utama )

3. Pemeriksaan Fisik

4. Pemeriksaan Penunjang

5. Program Pengobatan / Perawatan Pasien Hari Ini

FORMAT PENGKAJIAN KEPERAWATAN MATERNITAS

AKADEMI KEPERAWATAN JABAL GHAFUR SIGLI

Nama Mahasiswa : Tanggal Pengkajian :

NI M :

1. IDENTITAS PASIEN`
 Nama Pasien :
Umur :
Jenis Kelamin :
Suku :
Agama :
Pekerjaan :
Pendidikan :
Tanggal Masuk :
Alamat :
Diagnosa Medik :

2. RIWAYAT PENYAKIT
a. Keluhan Utama
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

b. Riwayat Penyakit Sekarang

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

c. Riwayat Kesehatan Yang Lalu Yang Mempengaruhi Kehamilan

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

d. Riwayat Kehamilan dan PersalinanYang Lalu

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

e. Riwayat Haid
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

f. Riwayat Genekologi
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

g. Riwayat Kesehatan Keluarga

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

h. Riwayat Perkawinan
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................
 i. Riwayat Kelahiran ( Kalau ada )
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

3. Pola Kebiasaan Sehari – Hari

a. Pola makan / minum
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

b. Pola istirahat / tidur

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

c. Pola eliminasi
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

d. Pola aktivitas
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

4. Data Psikologi
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

5. Data Social
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
6. Data Spiritual
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

7. Patofisiologi Diagnosa Medik

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
 ……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………………………………………………………....

8. Pemeriksaan Fisik
Keadaan Umum : Denyut Nadi :
Tingkat Kesadaran : Tekanan Darah :
Tinggi Badan : Pernafasan :
Berat Badan : Temperatur :

Lain – Lain : ( Head To Toe ) dengan cara inspeksi, palpasi, perkusi dan auskultasi

9. Pemeriksaan Penunjang

10. Therapi
 ANALISA DATA
NO DATA ETIOLOGI MASALAH
( Dapat dibuat lembaran lanjutannya pada kertas lain )

CATATAN PERKEMBANGAN
TGL NO. DX SOAPIER

. S:

O:

A:

P:

I:
 E:

R:

( Dapat dibuat lembaran lanjutannya pada kertas lain )

FORMAT PENGKAJIAN KEPERAWATAN MATERNITAS

AKADEMI KEPERAWATAN JABAL GHAFUR SIGLI

Nama Mahasiswa : Tanggal Pengkajian :

NI M :
2. IDENTITAS PASIEN`
Nama Pasien :
Umur :
Jenis Kelamin :
Suku :
Agama :
Pekerjaan :
Pendidikan :
Tanggal Masuk :
Alamat :
Diagnosa Medik :

2. RIWAYAT PENYAKIT
j. Keluhan Utama
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

k. Riwayat Penyakit Sekarang

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

l. Riwayat Kesehatan Yang Lalu Yang Mempengaruhi Kehamilan

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

m. Riwayat Kehamilan dan PersalinanYang Lalu

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

n. Riwayat Haid
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

o. Riwayat Genekologi
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

p. Riwayat Kesehatan Keluarga

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

q. Riwayat Perkawinan
.............................................................................................................................................................
.............................................................................................................................................................
 .............................................................................................................................................................
............................................................................................................................................................

r. Riwayat Kelahiran ( Kalau ada )

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

4. Pola Kebiasaan Sehari – Hari

e. Pola makan / minum
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

f. Pola istirahat / tidur

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

g. Pola eliminasi
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

h. Pola aktivitas
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

11. Data Psikologi

....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

12. Data Social

....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
13. Data Spiritual
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

14. Patofisiologi Diagnosa Medik

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
 ……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………………………………………………………....

15. Pemeriksaan Fisik

Keadaan Umum : Denyut Nadi :
Tingkat Kesadaran : Tekanan Darah :
Tinggi Badan : Pernafasan :
Berat Badan : Temperatur :

Lain – Lain : ( Head To Toe ) dengan cara inspeksi, palpasi, perkusi dan auskultasi

16. Pemeriksaan Penunjang

17. Therapi
 ANALISA DATA
NO DATA ETIOLOGI MASALAH
( Dapat dibuat lembaran lanjutannya pada kertas lain )

FORMAT PENGKAJIAN KEPERAWATAN ANAK

AKADEMI KEPERAWATAN JABAL GHAFUR SIGLI

Nama Mahasiswa : Tanggal Pengkajian :

NI M :

1. IDENTITAS PASIEN`
Nama Pasien :
Umur :
Jenis Kelamin :
Suku :
Agama :
Pekerjaan :
Pendidikan :
Tanggal Masuk :
Alamat :
Diagnosa Medik :

2. RIWAYAT PENYAKIT
a. Keluhan Utama
.............................................................................................................................................................
.............................................................................................................................................................

b. Riwayat Penyakit Sekarang

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
 .............................................................................................................................................................
.............................................................................................................................................................

c. Riwayat Penyakit Yang Lalu

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

d. Riwayat Penyakit Keluarga

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

e. Riwayat Imunisasi ( dalam bentuk tabel )

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

f. Riwayat Kehamilan dan Persalinan

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

g. Riwayat Kelahiran Sekarang

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
............................................................................................................................................................

h. Riwayat Tumbuh Kembang

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

3. Pola Kebiasaan Sehari – Hari

a. Pola makan / minum
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

b. Pola istirahat / tidur

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

c. Pola eliminasi
 .............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

d. Pola aktivitas
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

4. Data Psikologi
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

5. Data Social
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

6. Data Spiritual
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

7. Patofisiologi Diagnosa Medik

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………………………………………………………....

8. Pemeriksaan Fisik
Keadaan Umum : Denyut Nadi :
Tingkat Kesadaran : Tekanan Darah :
Tinggi Badan : Pernafasan :
Berat Badan : Temperatur :

Lain – Lain : ( Head To Toe ) dengan cara inspeksi, palpasi, perkusi dan auskultasi ( termasuk
antropometri )
9. Pemeriksaan Penunjang

10. Therapi
 ANALISA DATA
NO DATA ETIOLOGI MASALAH
( Dapat dibuat lembaran lanjutannya pada kertas lain )