PENGKAJIAN

I. BIODATA

Nama :............................................................

Umur :............................................................

Agama :............................................................

Alamat :............................................................

Pendidikan :............................................................

Pekerjaan :............................................................

Tinggal MRS :............................................................

Diagnosa Medis :............................................................

Nomor Register :............................................................

Tanggal Pengkajian :............................................................

II. KELUHAN UTAMA

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III. RIWAYAT PENYAKIT SEKARANG

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IV. RIWAYAT PENYAKIT MASA LALU

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V. RIWAYAT KESEHATAN KELUARGA

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VI. POLA AKTIVITAS SEHARI-HARI

1. Pola Tidur/Istirahat :

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2. Pola Eliminasi :

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3. Pola Makan/Minum :

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4. Pola Kebersihan Diri :

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5. Pola Kegiatan/Kebiasaan Lain :

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 6. Pola Hubungan Peran (Konsep Diri) :

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7. Pola Seksual :

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8. Pola penanggulanagan stress :

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VII. DATA PSIKOSOSIAL

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VIII. DATA SPIRITUAL

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IX. PEMERIKSAAN FISIK

A. Keadaan Umum

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B. Tanda-tanda Vital

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C. Pemeriksaan Kepala dan Leher

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D. Mata

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E. Hidung

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F. Telinga

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G. Mulut

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H. Integumen

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I. Thorak/Dada

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J. Abdomen

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K. Kelamin dan Daerah Sekitarnya

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L. Muskuloskeletal

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 M. Neurologi

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X. PEMERIKSAAN PENUNJANG

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XI. PENATALAKSANAAN/TERAPI

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