NAMA :

NIM :

PENGKAJIAN DAN PEMERIKSAAN FISIK

No RM : ...............................................................................................................
Hari/tanggal : ...............................................................................................................
Tempat : ...............................................................................................................

I. Pengkajian
A. IdentitasPasien
Nama :...................................................................................
Umur :...................................................................................
Tempattanggallahir :...................................................................................
Jeniskelamin :...................................................................................
Suku/bangsa :...................................................................................
Agama :...................................................................................
Pekerjaan :...................................................................................
Pendidikan :...................................................................................
Alamat :...................................................................................
Tanggal MRS :...................................................................................
DiagnosaMedis :...................................................................................
Ruangan :...................................................................................
Golongan Darah :...................................................................................
SumberInformasi :...................................................................................

B. IdentitasPenanggung Jawab
Nama :...................................................................................
Umur :...................................................................................
Jeniskelamin :...................................................................................
Suku/bangsa :...................................................................................
Agama :...................................................................................
Pekerjaan :...................................................................................
Pendidikan :...................................................................................
 Alamat :...................................................................................
Hubungandenganpasien :.................................................................................
C. Riwayat Kesehatan SaatIni (Nursing History)
1. Keluhan Utama
Jelaskan :...................................................................................
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2. Alasan Masuk RumahSakit

Jelaskan :...................................................................................
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3. Riwayat Penyakit
Jelaskan :...................................................................................
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D. Riwayat Kesehatan Masa Lalu
1. Penyakit Yang Pernah Dialami
Penyebab :...................................................................................
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Riwayat Perawatan :...................................................................................
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Riwayat Operasi :...................................................................................
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Riwayat Pengobatan:..................................................................................
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2. Kecelakaan Yang PernahDialami
Jelaskan :...................................................................................
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3. Riwayat Alergi
Jelaskan :...................................................................................
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E. Riwayat Kesehatan Keluarga (Genogram dan Keterangan)

F. Riwayat Psikologi dan Spiritual
1. Riwayat Psikologi
TempatTinggal :...................................................................................
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LingkuganRumah :...................................................................................
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HubunganAntarKeluarga :..........................................................................
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Pengasuh Anak :...................................................................................
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2. Riwayat Spiritual
Support System :...................................................................................
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KegiatanKegamaan:....................................................................................
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3. Riwayat Hospitalisasi
Jelaskan :...................................................................................
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G. Pola Fungsi Kesehatan (11 Pola Fungsional Gordon)

1. Pemeliharaan dan persepsiterhadapkesehatan
Jelaskan :...................................................................................
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2. Pola Nutrisi/metabolic
Jelaskan :...................................................................................
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3. Pola eliminasi
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4. Pola aktivitas dan latihan
Jelaskan :...................................................................................
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5. Pola tidur dan istirahat
Jelaskan :...................................................................................
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6. Pola kognitif-perseptual
Jelaskan :...................................................................................
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7. Pola persepsidiri/konsepdiri
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8. Pola seksual dan reproduksi
Jelaskan :...................................................................................
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9. Pola peran-hubungan
Jelaskan :...................................................................................
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10. Pola manajemenkoping stress
Jelaskan :...................................................................................
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11. Pola keyakinan-nilai

Jelaskan :...................................................................................
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H. PemeriksaanFisik
Hari:.............................. Tanggal :........................... Jam :...............
1. KeadaanUmum
a. Kesadaran
Jelaskan :...................................................................................
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b. PenampilanDigabungkandenganusia
Jelaskan :...................................................................................
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c. EkspresiWajah
Jelaskan :...................................................................................
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d. Personal hygiene/KebersihanSecaraUmum
Jelaskan :...................................................................................
e. Vital Sign
Jelaskan :...................................................................................
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2. PemeriksaanFisik Head To Toe

a. Kulit/Integument
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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b. Kepala dan Rambut
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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c. Kuku
 Inspeksi :...................................................................................
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Palpasi :...................................................................................
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d. Mata/Penglihatan
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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e. Hidung /penciuman
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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f. Telinga/Pendengaran
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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g. Mulut dan gigi
Inspeksi :...................................................................................
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h. Leher
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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i. Thorak/Dada
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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 Perkusi :...................................................................................
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Auskultasi :...................................................................................
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j. Jantung
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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Perkusi :...................................................................................
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Auskultasi :...................................................................................
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k. Abdoment
Inspeksi :...................................................................................
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Auskultasi :...................................................................................
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Palpasi :...................................................................................
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Perkusi :...................................................................................
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l. Perinium dan Genetalia

Inspeksi :...................................................................................
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m. Ekstermitas Atas dan Bawah
Inspeksi :...................................................................................
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Palpasi :...................................................................................
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3. Pengkajian Data Fokus (PengkajianSistem)

 a. SistemRespiratori
Jelaskan :...................................................................................
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b. SistemKardiovaskuler
Jelaskan :...................................................................................
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c. Sistem Gastrointestinal
Jelaskan :...................................................................................
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d. SistemUrinari
Jelaskan :...................................................................................
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e. SistemReproduksi
Jelaskan :...................................................................................
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f. SistemMuskuloskeletal
Jelaskan :...................................................................................
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g. SistemNeurologi
Jelaskan :...................................................................................
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4. Data penunjang
a. Program Terapi
1) …………………………………………….
2) ……………………………………………..
3) ……………………………………………..
4) ……………………………………………..
5) ……………………………………………..
6) ……………………………………………..

b. PemeriksaanFoto Rontgen
Hari/Tanggal :.....................................
Hasil Pemeriksaan

c. PemeriksaanPenunjangLaboratorium
Hari/Tanggal :.....................................
Hasil Pemeriksaan

Singaraja,..................2022
Yang Mengkaji,
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NIM...................................