PENGKAJIAN

Tgl / jam MRS : ...............................................

Ruang :...............................................
No Register :...............................................
Dx Medis :...............................................
Tgl pengkajian :...............................................

IDENTITAS KLIEN
Nama : ........................... Suami / istri / orang tua
Umur :........................... Nama :...........................
Jenis kelamin :........................... Pendidikan :...........................
Agama :........................... Pekerjaan : ...........................
Suku bangsa :........................... Alamat : ...........................
Bahasa :........................... Penanggung Jawab:
Pendidikan :........................... Nama : ...........................
Pekerjaan :........................... Pendidikan : ...........................
Status penikahan :........................... Pekerjaan : ...........................
Alamat : ........................... Alamat : ...........................

KELUHAN UTAMA:
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RIWAYAT PENYAKIT SEKARANG:
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Upaya yang telah dilakukan: ...........................................................................

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Terapi yang telah diberikan: ...........................................................................
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RIWAYAT PENYAKIT DAHULU:
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RIWAYAT KESEHATAN KELUARGA:
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Genogram

KEADAAN LINGKUNGAN YANG MEMPENGARUHI TIMBULNYA PENYAKIT:

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POLA FUNGSI KESEHATAN

1. Pola persepsi dan tata laksana kesehatan
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ADL DI RUMAH DI RUMAH SAKIT

2. pola nutrisi dan
metabolism
3. pola eleminasi

4. pola aktivitas

5. pola istirahat tidur

6. Pola kognitif dan persepsi sensori
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7. Pola konsep diri

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8. Pola hubungan peran

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9. Pola fungsi seksual – seksualitas

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10. Pola mekanisme koping

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11. Pola nilai dan kepercayaan

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PEMERIKSAAN FISIK
1. Status kesehatan umum
Keadaan / penampilan umum : .........................
Kesadaran :......................... GCS : ...............
BB sebelum sakit : ......................... TB : ...............
BB saat ini :.........................
BB ideal :.........................
Perkembangan BB :.........................
Status gizi :.........................
Status hidrasi :.........................
Tanda-tanda vital :.........................
TD : ......... mmHg Suhu : ......... °C
Nadi : ......... x/ menit RR : ......... x/ menit
2. Kepala
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3. Leher
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4. Thorax (dada)
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5. Abdomen
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6. Tulang belakang
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 7. Ekstrremitas
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8. Genitalia dan anus

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9. Pemeriksaan neurologis
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PEMERIKSAAN DIAGNOSTIK
1. Laboratorium
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2. Radiologi
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TERAPI
1. Oral
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2. Parenteral
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3. Lain-lain
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