Disusun Oleh :
NAMA : …………….........................
NIM : ………………………………..
KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKES
MALANG
JURUSAN KEPERAWATAN
FORMAT PENGKAJIAN
A. PENGKAJIAN
I. BIODATA
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E. ELIMINASI ALVI
Volume feses: ...................................................................................................................
Warna feses: ....................................................................................................................
Konsistensi: ....................................................................................................................
Frekwensi: .........................................................................................................................
Darah, lendir dalam feses: ................................................................................................
F. TIDUR
Jumlah jam tidur dalam 24 jam: .....................................................................................
Kualitas tidur (sering terbangun, rewel, tidak bisa tidur): ...............................................
G. PSIKOSOSIAL
Hubungan orangtua dengan anak: ......................................................................
Yang mengasuh: .........................................................................................................
X. TANDA-TANDA VITAL
a. Tekanan Darah : ............................................................................................................
b. Denyut Nadi : ............................................................................................................
c. Pernafasan : ............................................................................................................
d. Suhu Tubuh : ............................................................................................................
Denver
Normal
Suspect
Untestable
(Lampirkan formulir Denver)
B. Laboratorium
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
C. Pemeriksaan lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
Mengetahui, ...............................,......................................
Pembimbing klinik .
Mahasiswa
(.......................................................)
(............................................................)
NIM.
A2. ANALISIS DATA
HARI/TGL : ...............................................................................................
KEMUNGKINAN
NO DATA MASALAH
PENYEBAB
B. DIAGNOSA KEPERAWATAN
DIAGNOSA TANGGAL
NO
KEPERAWATAN
S: ..................................................................... S: S: ....................................................................
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O: O: O:
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A: A: A:
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P: P: P:
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Mengetahui,
Pembimbing Klinik Mahasiswa
(.......................................................) (............................................................)
NIM.