STATUS PASIEN

Inisial : Agama :
Sex : Pekerjaan :
Tgl Lhr : Alamat :
Tanggal :

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I. PENGAMATAN (Wang)
1. Sen :
a. Semangat :
b. Ekspresi Umum :
c. Sinar mata :
d. Kesadaran :
2. Se :
a. Warna kulit :
b. Ekspresi wajah :
3. Sing Tay :
a. Bentuk Tubuh :
b. Gerak gerik :
c. Sikap/posisi tubuh :
d. Keadaan 5 indera :
1) Mata :
2) Hidung :
3) Telinga :
4) Mulut :
5) Kulit :
6) Rambut :
7) Keringat :
4. Pemeriksaa Lidah
a. Selaput
1) Ketebalan :
2) Warna :
3) Kelembapan :
4) Lokasi selaput :
5) Sifat selaput :
b. Otot
1) Warna :
2) Gerak :
3) Bentuk :
4) Kelembapan :

Program Studi Pendidkan Ners FIK Unipdu Jombang 1

II. PENDENGARAN DAN PENCIUMAN (Wen)
1. Pendengaran :
a. Suara bicara :
b. Nafas :
c. Batuk :
d. Dahak :
e. Suara cegukan :
2. Penciuman :
a. bau mulut :
b. bau keringat :
c. bau riak :
d. Bau air seni :
e. Bau tinja :

III. ANAMNESA (Wun)

1. Keluhan utama :
2. keluhan tambahan :
3. riwayat penyakit :
4. Hal-hal khusus :
a. Suka panas/dingin :
b. Keringat :
c. Keluhan bagian tubuh
1) Kepala :
2) Dada :
3) Perut :
4) Pinggang :
5) Anggota gerak :
d. BAB :
e. BAK :
f. Makan/minum :
g. Kehausan :
h. Fungsi 5 indra :
i. Khusus :
Wanita : mentruasi/kehamilan), :
Pria : Kehidupan Sex, :
anak : vaksinasi, penyakit keturunan :

5. Syndroma patologi orga Chang Fu

a. Hati :
b. kandung empedu :
c. Jantung :
d. Usus Kecil :
e. Perikardium :
f. San ciao :

Program Studi Pendidkan Ners FIK Unipdu Jombang 2

 g. Ginjal :
h. Kandung kencing :
i. Paru :
j. Usus besar :
k. Limpa :
l. Lambung :

IV.PALPASI (CIE)
1. Lokal / daerah kelainan :
a. Nyeri tekan/enak :
b. kejang otot :
c. panas :
d. pembengkakan :
e. kelainan fungsi :

2. Palpasi 12 Organ Chan Fu

No Organ Shu belakang Mu depan Yuan
titik reaksi Titik Reaksi titik Reaksi
1 Paru
2 Jantung
3 Pericard
4 Limfa
5 Ginjal
6 Hati
7 Lambung
8 Usus besar
9 Usus kecil
10 Kandung kemih
11 Kandung emped
12 Sanciao

3. Perabaan nadi :
a. Umum :
(cepat/lambat, kuat/lemah, dalam/mengambang) :
b. Khusus ( nadi organ yang menderita kelainan )
Nadi Kanan Kiri
Luar/yang Dalam/yin Luar/yang Dalam/yin
CUN
Kuan
Ce

Gambaran nadi : normal / lemah / kuat

4. Pemeriksaan tambahan : Tensi, gula, asam urat, suhu tubuh, profil lemak, hasil ECG, Foto thorak
dan lain :
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Program Studi Pendidkan Ners FIK Unipdu Jombang 3

V. RINGKASAN KASUS (hal-hal yang menunjang diagnosa )
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VI. DIAGNOSA / KESIMPULAN

Diagnosa Kerja :
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a. Letak kelainan :
 Organ :
 Meridian :
b. Jenis kelainan :
c. Etiologi :

VII. RENCANA TERAPI

Tujuan Terapi :
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Titik dan penjelasan:
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Program Studi Pendidkan Ners FIK Unipdu Jombang 4
 ............................................................................................................................................ ....
Alat terapi :
Manipulasi :
Frekwensi :
Anjuran/nasehat :
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Pembimbing/instruktur Praktikan

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Program Studi Pendidkan Ners FIK Unipdu Jombang 5