LAMPIRAN

FORMAT PENGKAJIAN KEPERAWATAN (LENGKAP)

Tgl. Pengkajian : No. Register :

Jam Pengkajian : Tgl. Masuk :
Ruang/Kelas :

I. IDENTITAS

Identitas pasien Identitas Penanggung Jawab

1. Nama : 1. Nama :
2. Umur : 2. Umur Jenis Kelamin :
3. Jenis Kelamin : 3. Agama :
4. Agama : 4. Pekerjaan :
5. Pendidikan : 5. Alamat :
6. Pekerjaan : 6. Hubungan dengan Klien :
7. Gol. Darah :
8. Alamat :

II. KELUHAN UTAMA

1. Keluhan utama saat masuk Rumah Sakit

(keluhan utama yang dirasakan atau dialami klien yang menyebabkan klien atau keluarga mencari
bantuan kesehatan/masuk rumah sakit)
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2. Keluhan Utama saat Pengkajian
(Keluhan yang dirasakan oleh klien saat pengkajian dilakukan. Tanyakan pada klien keluhan apa yang
dirasakan, jika keluhan yang dirasakan klien lebih dari satu, tanyakan keluhan apa yang sangat
mengganggu klien)
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III. DIAGNOSA MEDIS

(Diisi dengan diagnose (penyakit) yang ditegakkan oleh dokter)
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IV. RIWAYAT KESEHATAN

1. Riwayat Penyakit Sekarang

(Adalah kronologis dari penyakit yang diderita saat ini mulai awal hingga di bawa ke RS secara lengkap.
Tindakan apa saja yang sudah dilakukan oleh klien untuk mengobati sakitnya sebelum ke RS)
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 2. Riwayat Kesehatan Yang Lalu
(Tanyakan riwayat penyakit yang pernah dialami klien beberapa waktu sebelumnya. Berapa kali klien
pernah sakit sebelum sakit yang sekarang? Bagaimana cara klien mencari pertolongan? Apakah klien
pernah menderita sakit DM (Diabetes Mellitus), HT (Hipertensi), TBC (Tuberkulosis Paru), Kanker dan
lain-lain)
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3. Riwayat Kesehatan Keluarga

(Tanyakan pada klien atau keluarga mengenai penyakit yang pernah diderita anggota keluarga. Jika
memungkinkan buatlah genogram atau gambaran garis keturunan beserta penyakit yang pernah
diderita terutama untuk penyakit-penyakit yang sifatnya diturunkan atau penyakit menular)
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V. PENGKAJIAN FUNGSIONAL

1. Aktivitas sehari-hari (ADL):

a. Pola nutrisi dan cairan

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b. Pola eliminasi
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c. Pola aktifitas dan latihan
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d. Pola istirahat tidur
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e. Pola kebersihan diri (Personal Hygiene)

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 f. Pola seksual dan reproduksi
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2. Kondisi Psikologi, Sosial dan Spriritual

a. Pola kognitif dan persepsi

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b. Pola persepsi diri dan konsep diri

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c. Pola hubungan dan peran

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d. Pola koping da toleransi stress

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e. Pola nilai dan kepercayaan

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f. Dampak perawatan di rumah sakit
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VI. PEMERIKSAAN FISIK
A. Survey keadaan umum

1. Penampilan dan perilaku:

a. Tingkat kesadaran secara kualitatif
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b. Gender dan ras
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 c. Usia
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d. Ekspresi wajah
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e. Jenis tubuh
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f. Postur
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g. Gaya berjalan
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h. Gerakan tubuh
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i. Higiene dan dandanan

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j. Afek dan mood

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k. Komunikasi
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l. Kekerasan terhadap klien
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2. Tanda-tanda Vital
- Tekanan darah (TD) : ---------- mmHg
- Nadi :----------- x/menit
- Suhu :-----------oC
- Respiratory Rate (RR) :---------- x/menit
 3. Antropometri
Tinggi badan : ---------------------------------
Berat badan : ---------------------------------
LLA : ---------------------------------
LK :----------------------------------

B. Pemeriksaan fisik sistem tubuh (head to toe)

1. Kulit, rambut dan kuku

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2. Kepala dan leher

a. Kepala
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b. Mata
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c. Telinga
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d. Hidung dan sinus

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e. Mulut
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f. Leher
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g. Kelenjar Tiroid
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3. Mata
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4. Dada dan paru

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5. Kardiovaskuler dan sistem vaskuler peripheral
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6. Payudara
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7. Abdomen
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8. Muskuloskeletal
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9. Genito-urinari
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10. Neurologis
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Yogyakarta, ............
Ttd

(nama perawat)
 Format Analis Data

No Hari/Tanggal Sign and Sympton/ Data Problem/ Masalah Etiology/ Penyebab

1. Ds:

Do:

2. Ds:

Do:
Prioritas Diagnosa keperawatan:
1.........

2.........
Format Perencanaan Keperawatan

No Hari/Tanggal Diagnosa Perencanaan

Keperawatan Tujuan (NOC) Intervensi Rasionalisasi
(NIC)
Format Implementasi dan Evaluasi

No Diagnosa Keperawatan Hari/Tgl Implementasi Evaluasi

1. S:

O:

A:

P: