Nama Mahasiswa (NIM):

Grup:

Tanggal Pengambilan Kasus:

Tanggal Pasien masuk Rumah Sakit:

I. DATA DEMOGRAFI PASIEN/ PATIENT’S DEMOGRAPHIC DATA:

1. Inisial/ Initials :
2. Usia/ Age :
3. Jenis kelamin/ Sex :
4. Agama/ Religion :
5. Status Perkawinan/ Civil status:
6. Pekerjaan/ Occupation :

II. PENGKAJIAN UMUM/ GENERAL ASSESSMENT:

1. Keluhan utama/ Chief complain/s:
2. Diagnosa Medis/ Diagnosis/Working diagnosis (medical):
i. Ringkasan mengenai penyakit/ Overview of the disease (maks. 1
halaman/ 1 page maximum)
ii. Prevalensi di Indonesia dan dunia/ Prevalence/incidence rates in
Indonesia and the in world

3. Riwayat penyakit saat ini/ History of present illness

i. Dalam urutan kronologis dari sejak kapan tanda dan gejala awal
terjadi/ In chronological order from when the signs or symptoms first
occurred.
ii. Penanganan yang sudah dilakukan/ Include any treatment done (medis,
tradisonal/ medical, traditional or home remedies)

4. Riwayat penyakit masa lalu/ Past medical history

i. Penyakit utama/ Major illnesses: ______ (sejak/ since _______)
ii. Kecelakaan/ Accidents/ major injuries: _______ (tahun/ year _____)
iii. Penanganan yang dilakukan untuk masalah diatas/ Include treatment
for the above problems:
1. ____________________
2. ____________________
3. ____________________

5. Riwayat kesehatan keluarga/ Family history

i. Penyakit keturunan/ Genetic/hereditary diseases:
 ii. Penyakit yang dialami anggota keluarga lainnya/ Familial diseases:

iii. Genogram

6. Pengkajian gaya hidup/ Lifestyle assessment

i. Merokok/ Smoking:
ii. Konsumsi alcohol/ Alcohol consumption: jelaskan frekuensi dan
jumlah/ include frequency and amount:
iii. Olah raga/ Exercise:
iv. Diet yang dijalankan/ Usual diet:

7. Pengkajian psikososial/ Psychosocial Assessment:

i. Konsep diri/ Self-concept:

ii. Peran dan relasi/ Roles and relations

III. PENGKAJIAN SISTIM TUBUH/ ASSESSMENT OF SYSTEMS:

1. Tanda-tanda vital/ Vital signs (selama pengkajian & dalam rentang 3 hari
sebelumnya/ during assessment & ranges for the past 3 days)
Tekanan Darah:
Frekuensi Nadi:
Frekuensi napas:
Suhu:

2. Tinggi dan Berat Badan, BMI/ Height, Weight and BMI:

3. Sistim Integumen/ Integument

 i. Kulit/ Skin: warna, edema, kelembapan, lesi, suhu, turgor, petekiae/
color, edema, moisture, lesions, temperature, turgor, petechie:

ii. Rambut/ Hair: distribusi, ketebalan, tekstur, infeksi kulit kepala/

distribution, thickness, and texture, scalp infection, scalp infestations,
scalp lesions, body hair:

iii. Kuku/ Nails: warna, bentuk/ color, curve

4. Sistim musculoskeletal/ Musculoskeletal

i. Kepala/ Head: ukuran, bentuk, kesimetrisan, palpasi ada tidaknya
nodul, massa atau penekanan, inspeksi kesimetrisan wajah dan
pergerakan wajah/ skull size, shape and symmetry, palpate skull for
nodules, masses or depressions, inspect the facial features for
symmetry, note for symmetry of facial movements:

ii. Tulang/ Bones- struktur, deformitas

(dislokasi/subluksasi/kontraktur/ankylosis), edema, nyeri tekan/
structure, deformities, edema, tenderness:

iii. Sendi/ Joints- pembengkakan, pergerakan, kesimetrisan sendi,

krepitasi, nodul, ROM (jelaskan dan tunjukkan bagian yang tidak
normal) / swelling, movement, crepitations, nodules, ROM

iv. Otot/ Muscle- ukuran otot bentuk otot (atrofi/hipertrofi), kontraktur,

pergerakan abnormal, tonus otot (spasme otot), kekuatan otot/

[5555 5555
5555 5555 ]muscle size, contractures, abnormal movements, muscle

tone, smoothness of movement, muscle strength:

5. Sistim Pernafasan/ Respiratory (hidung, leher & dada/ nose, neck & chest)
i. Hidung dan sinus/ Nose and sinuses: inspeksi hidung bagian luar untuk
mengkaji bentuk, ukuran, dan warna, perhatikan ada tidaknya flaring
atau cairang yang keluar, inspeksi rongga hidung, palpasi hidung
bagian luar untuk menentukan adanya area yang nyeri, massa, atau
masalah dengan tulang hidung/ inspect the external nose for shape,
size and color, note for flaring or discharges, inspect the nasal cavity,
lightly palpate the external nose to determine any areas of tenderness,
masses, and displacement of bones:

ii. Palpasi sinus frontalis dan maksilaris/ Palpate the frontal and
maxillary sinuses: transilluminate the frontal sinus and maxillary
sinus:

iii. Leher/ Neck: kaji otot leher, pergerakan kepala dan kekuatan otot,
palpasi nodul limfe, trakea dan kelenjar tiroid/ assess the neck muscles,
head movement and muscle strength, palpate the lymph nodes, trachea
and thyroid gland:

iv. Dada/ Chest: bentuk/ shape: kesimetrisan dan ekspansi dada, kelainan
bentuk tulang belakang, kaji taktil dan vocal fremitus, suara nafas/
symmetry and thoracic expansion, spinal alignment, asses tactile and
vocal fremitus, breath sounds:

v. Dada dan aksilla/ Breast and Axilla: inspeksi ukuran, kesmiterisan,

bentuk, inspeksi warna kulit, retraksi, pembengkakan, ada tidaknya
retraksi, isnpeksi ukuran areola, bentuk, ukuran, warna, ada tidaknya
massa atau lesi, inspeksi ukuran putting, bentuk, posisi, warna, ada
tidaknya cairang yang keluar, palpasi aksilla, dada dan putting/ inspect
size, symmetry, contour and shape, inspect skin color, retractions,
dimpling, swelling or edema, accentuate any retractions, inspect
areola for size, shape, symmetry, color, any masses or lesions, inspect
the nipples for size, shape, position, color, discharges, lesions, palpate
the axillary, sub-clavicular, supraclavicular lymph nodes, palpate the
breast and nipples:
6. Sistim Kardiovaskuler/ Cardiovascular
i. Jantung/ Heart: inspeksi dan palpasi precordial, auskultasi suara
jantung, nadi apical/ inspect and palpate the precordium, auscultate
heart sounds, apical pulse:

ii. Sistim vascular perifer/ Peripheral vascular system: nadi perifer, arteri
karotis, vena jugularis, vena perifer, perfusi perifer/ peripheral pulses,
carotid arteries, jugular vein, peripheral veins, peripheral perfusion:

iii. Hitung MAP/ *calculate: MAP, pulse pressure and pulse deficit

7. Sistim saraf sensorik/ Neuro-sensory

i. Mata/ Eyes: inspeksi stuktur mata eksternal, inspeksi adanya edema,
karakteristik kelopak mata, kemampuan berkedip, inspeksi
konjungtiva, palpasi ductus nasolakrimalis, lakukan tes sensitifitas
kornea, kaji PERRLA, kaji otot-otot ekstraokular, kaji kemampuan
visual/ inspect the external eye structures, inspect for edema and
hollowness of the eyes, inspect the eyelids for surface characteristics,
ability to blink, inspect the conjunctiva, palpate the nasolacrimal duct,
lacrimal sac and gland, perform cornea sensitivity test, assess for
PERRLA, assess the extraocular muscles, assess visual acuity :

ii. Telinga/ Ears: inspeksi daun telinga, warna, kesimterisan dan posisi,
inspeksi lubang telinga dan membran timpani, palpasi tekstur,
elastisitas daun telinga, kaji kemampuan pendengaran, tes Weber, tes
Rinne/ inspect the auricles for color, symmetry, and position, Inspect
the ear canal and tympanic membrane, palpate the auricles for
texture, elasticity, and tenderness, assess gross hearing acuity,
Weber’s test, Rinne test:

iii. Pengkajian neurologi/ Neurologic assessment:

1. Status mental/ Mental status exam: bahasa/ language (sensory,
motor & mixed), orientasi/ orientation (time, place, person),
ingatan/ memory (immediate recall, recent, remote), rentang
 perhatian/ attention span and calculation, tingkat kesadaran
kualitatif & kuantitatif:

reflexes · (biceps, triceps, brachioradialis, patellar, plantar

(Babinski) kekuatan reflex:

2. Fungsi motoric/ Motor functions: keseimbangan, gaya jalan

(Tegap, membungkuk spastic, scissor, propulsive, foot drop,
waddling)/ gross motor balance (standing in one foot, heel-to-
toe walking, toe or heel walking), Romberg’s test, kaji
koordinasi gerak/ assess coordination: (finger-to-nose test):

3. Fungsi sensorik/ Sensory function: kaji sensasi/ assess

sensation (light touch, pain, temperature discrimination, tactile
discrimination), position or kinesthetic sensation, stereognosis:

8. Sistim pencernaan/ Gastro-intestinal

i. Bibir dan mukosa mulut/ Lips and buccal Mucosa: inspect lips for
symmetry of contour, color, and texture, inspect and palpate the inner
lips and buccal mucosa for color, moisture, texture, and lesions:

ii. Gigi dan gusi/ Teeth and gums: inspect the teeth and gums while
examining the buccal mucosa, inspect the dentures (if applicable)

iii. Lidah/ Tongue and floor of mouth: inspect the surface for position,
color, texture, inspect the tongue, mouth floor, and frenulum, assess
tongue movement, palpate the tongue and floor of mouth for any
nodules, lumps, or excoriated areas

iv. Palatum dan uvula/ Palates and uvula: inspect the hard and soft palate
for color, shape, texture, and the presence of bony prominence, inspect
the uvula for position and mobility:
 v. Oroparing dan tonsil/ Oropharynx and tonsils: inspect the oropharynx
for color and texture, inspect the tonsils (color, discharges, size),
assess swallowing and gag reflexes:

vi. Abdomen: inspect for skin integrity, contour, and symmetry, observe
abdominal movements, auscultate for bowel sounds, vascular sounds,
peritoneal friction rub, percuss liver and spleen, palpate the four
quadrants:

vii. Rektal dan anus/ Rectum and Anus: note color of feces, inspect the
anus and surrounding tissue for color, skin integrity, palpate the
rectum for anal sphincter (tonicity, nodules, masses/tenderness),
palpate the prostate gland:

9. Sistim perkemihan dan reproduksi/ Genito-urinary and reproductive

i. Intake dan output cairan/ Fluid intake and output:

ii. Palpasi kandung kemih/ *palpate the bladder (selama pengkajian

abdomen/ during assessment of the abdomen):

iii. Kelamin perempuan/ Female Genitalia: inspect the distribution,

amount, and characteristic of pubic hair, inspect the skin of the pubic
area for parasites, swelling and lesions, inspect the urinary meatus,
clitoris, vaginal orifice, cervical os and vagina, palpate the Skene’s
grand and Bartholin’s gland, assess the pelvic musculature :

iv. Kelamin laki-laki/ Male Genitalia: inspect the distribution, amount

and characteristics of the pubic hair, penile shaft and the glans penis
for lesions, nodules, and inflammation, inspect the urethral meatus for
swelling, inflammation and discharges, inspect the scrotum for
appearance, general size and symmetry, palpate the penis for
tenderness, thickening and nodules, palpate the scrotum, palpate the
inguinal area for bulges
IV. RINGKASAN TEMUAN PENGKAJIAN YANG SIGNIFIKAN/ SUMMARY OF
SIGNIFICANT ASSESSEMENT FINDINGS (hanya temuan yang abnormal/ only
the abnormal findings)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
V. TES DIAGNOSTIK/ DIAGNOSTIC TESTS

1. Studi visualisasi/ Visualization studies (x-ray, 2D echo, angiography, endoscopy, CT-scan, MRI)
2. Lainnya/ Others (ECG, stress test, sensitivity test)

Tanggal dan Nama Hasil pemeriksaan Implikasi/ Implication/s Catatan/ Notes

waktu/ Date and pemeriksaan/ pasien/ Patient’s result
time Name of test

3. Tes laboratorium/ Laboratory tests (dalam 3 hari terakhir/ 3 days)

Tanggal dan Nama Tujuan/ Nilai normal/ Hasil Implikasi/ Catatan/ Notes
waktu/ Date pemeriksaan/ Purpose Normal Values pemeriksaan Implication/s
and time Name of test pasien/
Patient’s result
VI. RINGKASAN STATUS FUNGSIONAL PASIEN/ SUMMARY OF THE PATIENT’S FUNCTIONAL STATUS:

Klasifikasi Pola Fungsi Gordon/ Tanda dan gejala yang berhubungan/ Related Signs and Symptoms
Gordon’s Functional Classification

1. Manajemen Kesehatan dan

persepsi/ Health Perception
and Health Management
2. Nutrisi dan metabolism/
Nutrition and Metabolism
3. Eliminasi/ Elimination
4. Aktivitas dan Latihan/ Activity
and Exercise
5. Persepsi dan kognitif/
Cognition and Perception
6. Tidur dan istirahat/ Sleep and
Rest
7. Persepsi dan konsep diri/ Self-
Perception and Self-Concept
8. Peran dan hubungan/ Roles and
Relationships
9. Seksualitas dan reproduksi/
Sexuality and Reproduction
10. Toleransi stress dan koping/
Coping and Stress Tolerance
11. Nilai dan kepercayaan/
Values and Belief
VII. INTERVENSI MEDIS/ MEDICAL INTERVENTIONS:
1. Diet:
2. Batasan aktivitas/ Activity restrictions:
3. Batasan cairan/ Fluid restrictions: ____ mL per ____

RINGKASAN PROSEDUR TINDAKAN MEDIS/ SUMMARY OF PROCEDURES:

Tanggal/ Date Nama Tindakan/ Name of Indikasi/ Indication/s Kemungkinan komplikasi/ Possible
procedure complication/s

RINGKASAN OBAT-OBATAN/ SUMMARY OF MEDICATIONS:

Tanggal/ Date Nama obat, dosis, rute, Klasifikasi Mekanisme kerja/ Indikasi dan alasan Efek samping dan hal yang perlu
cara pemberian/ Name obat/ Action pemberian pada diperhatikan/ Side effects and/or
of meds Classification pasien/ Indication/s adverse reactions

VIII. DAFTAR DIAGNOSA KEPERAWATAN/ LIST OF NURSING DIAGNOSIS (sesuai prioritas/ according to priotity)
1.
2.
3.
4.
5.
Dst
 IX. RENCANA KEPERAWATAN/ NURSING CARE PLAN
(untuk 3 diagnosa keperawatan prioritas/ for the top 3 priority nursing diagnosis)

Data Data Diagnosa Hasil yang Intervensi/ Rasional/ Rationale Implementasi Evaluasi/ Evaluation
subjektif/ Objektif/ keperawatan/ diharapkan/ Intervention
Subjective Objective Nursing Outcome
Data Data Diagnosis Objectives

X. RENCANA PULANG/ DISCHARGE PLAN

XI. RINGKASAN KASUS/ SUMMARY OF THE CASE (Concept Map)

XII. TREN ATAU TEMUAN TERBARU SAAT INI/ NEW TRENDS OR EVIDENCE
1. A new technique, diagnostic test or intervention for this disease.

XIII. DAFTAR PUSTAKA/ REFERENCES