FORMAT
FORMAT
JURUSAN KEPERAWATAN
FAKULTAS KESEHATAN
UNIVERSITAS TRIBHUWANA TUNGGADEWI - MALANG
A. PENGKAJIAN
1. Biodata Klien
a. Nama : An. A
b. Umur : 1 tahun 6 bulan
c. Jenis kelamin : Laki-Laki
d. Agama : Islam
e. Suku / Bangsa : Jawa/Indonesia
f. Alamat : T;ogomas, Malang
g. No. Register : 002234
h. Tanggal Masuk RS : 19 Juli 2020
i. Tanggal Pengkajian : 19 Juli 2020
j. Diagnosa Medis : Hernia Scrotalis
k. Nama Orang Tua : Ny. B
b. Riwayat Natal
1
2
5. Riwayat Imunisasi
GENOGRAM
2
3
b. Aspek Sosial
9. Pola Aktifitas-Latihan
Rumah Rumah Sakit
Makan/minum .................................................... ....................................................
Mandi .................................................... ....................................................
Berpakaian/berdandan .................................................... ....................................................
Toileting .................................................... ....................................................
Mobilitas di tempat tidur ....................................................
Berpindah .................................................... ....................................................
Berjalan .................................................... ....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = tidak mampu
3
4
BAK:
- Frekuensi/pola .................................................... .................................................
- Warna & Bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................
Pola Perkembangan
1. Keadaan umum :
a. Kesadaran :
b. Tanda-tanda vital : - Tekanan Darah : Suhu :
- Nadi : Pernafasan :
c. Tinggi Badan : Berat Badan :
LK : LD : LLA :
2. Kepala dan Leher
a. Kepala : Bentuk Massa
Distribusi rambut Warna kulit kepala
b. Mata : Bentuk Konjungtiva
Pupil : ( ) reaksi terhadap cahaya ( ) isokor ( )Miosis
Tanda-tanda radang :
Funsi penglihatan : ( ) Baik ( ) Kabur
4
5
Radiologi
5
6
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17. Kesimpulan
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Malang.
Pengkaji
A. ANALISIS DATA
HARI/TGL : ...............................................................................................
6
7
7
8
B. DIAGNOSA KEPERAWATAN
8
9
9
10
10
11
E. EVALUASI
DIAGNOSA TANGGAL
NO
KEPERAWATAN
S: .................................................................. S: S: ..................................................................
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O: O: O:
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....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
11
12
A: A: A:
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....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
P: P: P:
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Malang,..............................,...............
........................
Mengetahui,
Pembimbing Klinik
Mahasiswa
(.......................................................)
(............................................................)
N
12
13
13