Format Pengkajian TB Paru

I. DATA UMUM

Nama : ……………………………
Ruang : ……………………………
No. Register : ……………………………
Umur : ……………………………
Jenis Kelamin : ……………………………
Agama : ……………………………
Suku Bangsa : ……………………………
Alamat : ……………………………
Pekerjaan : ……………………………
Status : ……………………………
Pendidikan Terakhir : ……………………………
Tanggal MRS : ……………………………
Tanggal Pengkajian : ……………………………
Diagnosa Medis : ……………………………

II. DATA DASAR

Keluhan Utama :
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………

Alasan Masuk Rumah Sakit :

……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………

Riwayat Penyakit Sekarang

: ..........................................................................................
.........................................

Upaya yang telah dilakukan:

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Terapi yang telah diberikan:

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Riwayat Kesehatan Dahulu

: .................................................................................
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Riwayat Kesehatan
Keluarga : .................................................................................
 ...................................................................................................................................
Genogram:

III.POLA FUNGSI KESEHATAN

1. Persepsi terhadap Kesehatan – Manajemen Kesehatan

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2. Pola Aktivitas dan Latihan

 Kemampuan Perawatan Diri

Skor 0 : mandiri, 1 : dibantu sebagian, 2 : perlu bantuan orang lain, 3 :
perlu bantuan orang lain dan alat, 4 : tergantung pada orang lain / tidak
mampu.

Aktivitas 0 1 2 3 4
Mandi
Berpakaian
Eleminasi
Mobilisasi di tempat tidur
Pindah
Ambulasi
Naik tangga
Makan dan minum
Gosok gigi

Keterangan : ........................................................................................................
......
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3. Pola Istirahat dan Tidur :

KETERANGAN SEBELUM SAKIT SAAT SAKIT

Jumlah Jam Tidur Siang

Jumlah Jam Tidur Malam

Pengantar Tidur
 Gangguan Tidur

Perasaan Waktu Bangun

4. Pola Nutrisi – Metabolik

KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi

Jenis

Porsi

Total Konsumsi

Keluhan

5. Pola Eliminasi

Eliminasi Uri
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi

Pancaran

Jumlah

Bau

Warna

Perasaan setelah BAK

Total Produksi Urin

Eliminasi Alvi
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi

Konsistensi

Bau
 Warna

6. Pola Kognitif dan Persepsi Sensori

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7. Pola Konsep Diri

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8. Pola Mekanisme Koping

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9. Pola Fungsi Seksual – Reproduksi

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10. Pola Hubungan - Peran

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11. Pola Nilai dan Kepercayaan
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Nilai Khusus

Praktik Ibadah

Pengetahuan tentang
Praktik Ibadah selama sakit

IV. PEMERIKSAAN FISIK (DATA OBYEKTIF)

1. Status Kesehatan Umum

Keadaan/ penampilan umum:
Kesadaran : GCS:
BB sebelum sakit : TB:
BB saat ini :
Tanda – tanda vital :
TD :
N :
Suhu :
RR :
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. Ekstremitas
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7. Genitallia dan Anus

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Pemeriksaan Diagnostik
1. Laboratorium

2. Radiologi

Terapi
1. Oral

2. Parenteral

3. Lain - lain