KEMENTERIAN KESEHATAN R.

I
POLITEKNIK KESEHATAN
JAMBI JURUSAN
KEPERAWATAN
JL.DR. TAZAR NO. 05 KELURAHAN BULURAN KENALI KEC. TELANAIPURA JAMBI

FORMAT PENGKAJIAN KEPERAWATAN

Tanggal/ Jam Masuk RS : ................................................................

Ruang : ................................................................
No. Register : ................................................................
Diagnosa Medis : ................................................................
Tanggal Pengkajian : ................................................................

IDENTITAS KLIEN
Nama : ............................................ Suami/Isteri/Ortu :
Umur : ............................................ Nama : ......................................
Jenis Kelamin : ............................................ Pekerjaan : ......................................
Agama : ............................................ Alamat : ......................................
Suku/ Bangsa : ............................................ ......................................
Bahasa : ............................................ Penanggung : ......................................
Jawab
Pendidikan : ............................................ Nama : ......................................
Pekerjaan : ............................................ Alamat : ......................................
Status : ............................................ ......................................
Alamat : ............................................
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KELUHAN UTAMA
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RIWAYAT PENYAKIT SEKARANG

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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

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 Genogram :

KEADAAN LINGKUNGAN YANG MEMPENGARUHI TIMBULNYA PENYAKIT

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POLA FUNGSI KESEHATAN

1. Pola Persepsi Dan Tata Laksana Kesehatan
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2. Pola Nutrisi Dan Metabolisme

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3. Pola Eliminasi
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4. Pola Aktivitas
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5. Pola Istirahat Tidur

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6. Pola Kognitif Dan Persepsi Sensori

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7. Pola Konsep Diri

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8. Pola Hubungan Peran
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9. Pola Fungsi Seksual-Seksualitas

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10. Pola Mekanisme Koping

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11. Pola Nilai Dan Kepercayaan

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PEMERIKSAAN FISIK
1. Status Kesehatan Umum
Keadaan/ Penampilan Umum :
Kesadaran : ................................................. GCS : ......................................
BB sebelum sakit : ................................................. TB : ......................................
BB saat ini : .................................................
BB ideal : .................................................
Perkembangan BB : .................................................
Status Gizi : .................................................
Status Hidrasi : .................................................

Tanda-tanda vital :
TD...................mmHg Suhu : .................. 0C
N.....................x/mnt RR : ..................
x/mnt
2. Kepala
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3. Leher
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4. Thorak (dada)
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5. Abdomen
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6. Tulang Belakang
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7. Ekstremitas
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8. Genitalia dan Anus

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9. Pemeriksaan Neurologis
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PEMERIKSAAN DIAGNOSTIK
1. Laboratorium
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2. Radiologi
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3. Lain-lain
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TERAPI
1. Oral
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2. Parenteral
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3. Lain-lain
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Jambi, ................................................
Mahasiswa

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NIM. ..................................................
ANALISA DATA

NO DATA PENYEBAB MASALAH

1. Data subjektif :

Data Objektif
DIAGNOSIS KEPERAWATAN
INTERVENSI KEPERAWATAN

No.
Tanda Tanda
Diagnosis Tujuan Intervensi
Perawat
Keperawatan
IMPLEMENTASI KEPERAWATAN

No. Diagnosis Tanda Tanda

Implementasi
Keperawatan Perawat
EVALUASI

No. Diagnosis Tanda Tanda

Evaluasi (SOAP)
Keperawatan Perawat