PENGKAJIAN DATA

KEBUTUHAN DASAR MANUSIA

BIODATA
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KESEHATAN KLIEN RIWAYAT

1. Keluhan Utama / Alasan Masuk Rumah Sakit :
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Kesehatan Yang Lalu :
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4. Riwayat Kesehatan Keluarga :
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PEMENUHAN KEBUTUHAN DASAR

A. POLA MAKAN DAN MINUM :

Sebelum sakit : .....................................................................................................................

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Setelah sakit:
1. Jumlah dan jenis makanan : ...........................................................................................
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2. Waktu Pemberian Makan :............................................................................................
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3. Jumlah dan Jenis Cairan :............................................................................................
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4. Waktu Pemberian Cairan :.............................................................................................
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5. Pantangan :....................................................................................................................
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6. Masalah Makan dan Minum : ...................................................................................
a. Kesulitan mengunyah : ...................................................................................
b. Kesulitan menelan : ...................................................................................
c. Mual dan Muntah : ....................................................................................
d. Tidak dapat makan sendiri : ....................................................................................

B. POLA ELIMINASI :

Sebelum sakit : .....................................................................................................................

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Setelah sakit:
1. BAB : ......................................................................................................................
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2. BAK : ......................................................................................................................
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3. Kesulitan BAB/BAK : ...................................................................................................
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C. POLA TIDUR/ISTIRAHAT :

Sebelum sakit : .....................................................................................................................

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Setelah sakit:
1. Waktu tidur : ...................................................................................................
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2. Waktu Bangun : ...................................................................................................
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3. Masalah tidur : ...................................................................................................
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D. KEBERSIHAN DIRI/PERSONAL HYGIENE :

Sebelum sakit : .....................................................................................................................

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Setelah sakit:
1. Pemeliharaan Badan : ...................................................................................................
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2. Pemeliharaan Gigi dan Mulut :.......................................................................................
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3. Pemeliharaan Kuku : .....................................................................................................
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E. RIWAYAT PSIKOSOSIAL

Sebelum sakit : .....................................................................................................................

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Setelah sakit:
a. Hubungan dengan orang lain / Interaksi social : ...........................................................
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F. AMAN DAN NYAMAN

Sebelum sakit : .....................................................................................................................
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Setelah sakit: ........................................................................................................................
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G. OKSIGENASI
Sebelum sakit : .....................................................................................................................
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Setelah sakit: ........................................................................................................................
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H. SPIRITUAL
Sebelum sakit : .....................................................................................................................
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Setelah sakit: ........................................................................................................................
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I. SEKSUAL
Sebelum sakit : .....................................................................................................................
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Setelah sakit: ........................................................................................................................
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J. TERMINAL / MENJELANG AJAL

Sebelum sakit : .....................................................................................................................

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Setelah sakit: ........................................................................................................................
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PEMERIKSAAN FISIK :
A. Kesan Umum / Keadaan Umum :.........................................................................................
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B. Tanda-tanda Vital
Suhu Tubuh : …………. C Nadi : ……………..kali/menit
Tekanan darah : ……../…… mmHg Respirasi : ……………..kali/menit

Tinggi badan : …………..cm Berat Badan : …………..kg

C. Pemeriksaan Kepala dan Leher :
1. Kepala dan rambut
b. Bentuk Kepala:..........................................................................................................
c. Rambut :..........................................................................................................
d. Warna :..........................................................................................................

2. Mata
a. Kelengkapan dan Kesimetrisan :
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b. Konjuctiva dan selera :
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 c. Pupil :
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3. Hidung
a. Tulang Hidung dan Posisi Septum Nasi :
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b. Lubang Hidung :
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c. Cuping Hidung :
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4. Telinga : .........................................................................................................................
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5. Mulut dan Faring :

a. Keadaan Bibir :.........................................................................................................
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b. Keadaan Gusi dan Gigi :
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6. Leher :
a. Kelenjar Lymphe :..............................................................................................

D. Pemeriksaan Integumen (Kulit) :

a. Kebersihan :.....................................................................................
b. Warna :.....................................................................................
c. Turgor :.....................................................................................
d. Kelembaban :.....................................................................................
e. Kelainan pada Kulit :.....................................................................................
E. Pemeriksaan Payudara (jika klien perempuan):
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F. Pemeriksaan Thorak / Dada :
1. Inspeksi Thorak
a. Bentuk Thorak :.....................................................................................
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b. Pernafasan
- Frekuensi :.....................................................................................
- Irama :.....................................................................................

e. Tanda-tanda kesulitan bernafas :

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2. Pemeriksaan Paru
a. Palpasi getaran suara (vocal Fremitus)
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b. Perkusi :
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c. Auskulasi
- Suara nafas :
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- Suara tambahan :
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3. Pemeriksaan Jantung :
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G. Pemeriksaan Abdomen
a. Inspeksi
- Bentuk Abdomen : ................................................................................................
- Benjolan/massa :................................................................................................
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b. Auskultasi
- Peristaltik Usus :.........................................................................................
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c. Palpasi
- Tanda nyeri tekan :.........................................................................................
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- Benjolan/massa :.........................................................................................
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- Tanda-tanda Ascites :.........................................................................................
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- Hepar :.........................................................................................
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- Lien :.........................................................................................
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d. Perkusi
- Suara Abdomen :.........................................................................................
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H. Genetalia
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I. Pemeriksaan Muskuloskeletal (Ekstrimitas)

a. Kesimetrisan otot :..............................................................................................
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b. Pemeriksaan Edema :..............................................................................................
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c. Kekuatan otot :..............................................................................................
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J. Pemeriksaan Neurologi
1. Tingkat kesadaran (secara kwantitatif)/ GCS :
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2. Fungsi Motorik :
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3. Fungsi Sensorik :
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4. Refleks :
a. Refleks Fisiologis :..................................................................................................
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b. Refleks Patologis :..................................................................................................
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PEMERIKSAAN PENUNJANG

1. Laboratorium :..........................................................................................................
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2. Rontgen :..........................................................................................................
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3. ECG :..........................................................................................................
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4. USG :..........................................................................................................
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5. Lain – lain :..........................................................................................................
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PENATALAKSANAAN DAN TERAPI

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