FORMAT PENGKAJIAN
AKTIVITAS DAN MOBILITAS
Minum
Frekuensi ............................... ................................
Jenis ............................... ................................
Jumlah ............................... ................................
Keluhan ............................... .................................
c. Pola Eliminasi
Kebiasaan BAB
Keterangan Sebelum Sakit Saat Sakit
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total
e. Pola Istirahat-Tidur
Keterangan Sebelum Sakit Saat Sakit
Lama tidur siang
Lama tidur malam
Pengantar tidur
Gangguan tidur
3 RR .......................................... ..................................
TB :................................cm
BB saat ini :................................Kg
BB Ideal :.................................Kg
2. Kepala
Rambut :………………………………………………………………………….......
Wajah : ……………………………………………………………………….........
Mata : ……………………………………………………………………….........
Hidung :………………………………………………………………………….......
Mulut :………………………………………………………………………….......
Gigi :………………………………………………………………………….......
Telinga :………………………………………………………………………….....
3. Leher
I.........................................................................................................................................
P........................................................................................................................................
5. Dada
Paru-Paru
I……………………………………………………………………………………………………
P........................................................................................................................................
P........................................................................................................................................
A………………………………………………………………………………………………….
Jantung
I……………………………………………………………………………………………………
P........................................................................................................................................
P........................................................................................................................................
A………………………………………………………………………………………………….
6. Abdomen
I…………………………………………………………………………………………………..
A…………………………………………………………………………………………………
P…………………………………………………………………………………………………
P………………………………………………………………………………………………….
7. Ekstremitas
Atas
I…………………………………………………………………………………………………..
P………………………………………………………………………………………………….
Gerakan Sendi…………………………………………………………………………………
…………………………………………………………………………………………………….
Kekuatan Otot…………………………………………………………………………………
Bawah
I………………………………………………………………………………………………….
P…………………………………………………………………………………………………
Gerakan Sendi………………………………………………………………………………..
………………………………………………………………………………………………….
Kekuatan Otot…………………………………………………………………………………
9. Anus – Genetalia
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
………………,…………………..20…..
Mahasiswa
( )
NIM…………………………