Adelvia RK
Adelvia RK
BIODATA
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B. POLA ELIMINASI :
1. BAB : ......................................................................................................................
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2. BAK : ......................................................................................................................
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3. Kesulitan BAB/BAK : ...................................................................................................
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C. POLA TIDUR/ISTIRAHAT :
1. Waktu tidur : ...................................................................................................
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2. Waktu Bangun : ...................................................................................................
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3. Masalah tidur : ...................................................................................................
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D. KEBERSIHAN DIRI/PERSONAL HYGIENE :
1. Pemeliharaan Badan : ...................................................................................................
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2. Pemeliharaan Gigi dan Mulut :.......................................................................................
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3. Pemeliharaan Kuku : .....................................................................................................
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RIWAYAT PSIKOSOSIAL
A. Hubungan dengan orang lain / Interaksi social : ..........................................................
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PEMERIKSAAN FISIK :
A. Kesan Umum / Keadaan Umum :.........................................................................................
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B. Tanda-tanda Vital
Suhu Tubuh : …………. C Nadi : ……………..kali/menit
Tekanan darah : ……../…….. mmHg Respirasi : ……………..kali/menit
- Suara tambahan :
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3. Pemeriksaan Jantung :
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G. Pemeriksaan Abdomen
a. Inspeksi
- Bentuk Abdomen : ................................................................................................
- Benjolan/massa :................................................................................................
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b. Auskultasi
- Peristaltik Usus :.........................................................................................
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c. Palpasi
- Tanda nyeri tekan :.........................................................................................
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- Benjolan/massa :.........................................................................................
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- Tanda-tanda Ascites :.........................................................................................
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- Hepar :.........................................................................................
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- Lien :.........................................................................................
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d. Perkusi
- Suara Abdomen :.........................................................................................
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H. Genetalia
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J. Pemeriksaan Neurologi
1. Tingkat kesadaran (secara kwantitatif)/ GCS :
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2. Fungsi Motorik :
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3. Fungsi Sensorik :
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4. Refleks :
a. Refleks Fisiologis :..................................................................................................
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b. Refleks Patologis :..................................................................................................
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PEMERIKSAAN PENUNJANG
A. Pemeriksaan Diagnostik/ Penunjang Medis :
1. Laboratorium :..........................................................................................................
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2. Rontgen :..........................................................................................................
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3. ECG :..........................................................................................................
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4. USG :..........................................................................................................
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5. Lain – lain :..........................................................................................................
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PENATALAKSANAAN DAN TERAPI
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Perawat
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NIM :
ANLISA DATA
NO DATA SUBJEKTIF DATA OBJEKTIF
DIAGNOSA KEPERAWATAN :
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FORMAT INTERVENSI
NO IMPLEMENTASI EVALUASI
DX
1 S
A
P
2 S
O
A
DST