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GENOGRAM
(minimal 3 generasi, riwayat penyakit keluarga, tandai pasien dengan tanda
panah)
F. Riwayat ingkungan
Jenis Rumah Pekerjaan
• !e"ersihan .........................................
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• #ahaya ke$elakaan .........................................
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• %&lusi .........................................
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• 'entilasi .........................................
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• %en$ahayaan .........................................
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G. %&la Aktiitasatihan
Rumah Rumah Sakit
• Makan*minum .........................................
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• Mandi .........................................
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• #erpakaian*"erdandan .........................................
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• +&ileting .........................................
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.........................................
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• M&"ilitas di tempat
tidur
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• #erpindah .........................................
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• #eralan .........................................
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• Naik tangga .........................................
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Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4
= tidak mampu
-. %&la Nutrisi Meta"&lik
Rumah Rumah Sakit• enis diit*makanan ......................................
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........................................
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• Frekuensi*p&la ......................................
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• %&rsi yang diha"iskan ......................................
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• !&mp&sisi menu ......................................
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• %antangan ......................................
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• Napsu makan ......................................
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........................................
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• Fluktuasi ## / "ulan
terakhir
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........................................
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• enis minuman ......................................
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• Frekuensi*p&la minum ......................................
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• Gelas yang
diha"iskan
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• 0ukar menelan
(padat*$air)
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• %emakaian gigi palsu
(area)
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• Riwayat masalah
penyem"uhan luka
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1. %&la Eliminasi
Rumah Rumah Sakit
• #A#
− Frekuensi*p&la .........................................
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.........................................
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− !&nsistensi .........................................
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.........................................
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− 2arna "au .........................................
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− !esulitan .........................................
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− 4paya mengatasi .........................................
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•
#A! − Frekuensi*p&la .........................................
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− !&nsistensi .........................................
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− 2arna "au .........................................
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.........................................
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− !esulitan .........................................
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− 4paya mengatasi .........................................
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.........................................
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. %&la +idur1stirahat
Rumah Rumah Sakit
• +idur siang 5 amanya .........................................
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− am ..... s*d ..... .........................................
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− !enyamanan
setelah tidur
.........................................
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• +idur malam 5
amanya
.........................................
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.........................................
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− am ..... s*d ..... .........................................
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− !enyamanan
setelah tidur
.........................................
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− !e"iasaan se"elum
tidur
.........................................
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....− !esulitan .........................................
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− 4paya mengatasi .........................................
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!. %&la !e"ersihan 6iri
Rumah Rumah Sakit
•
Mandi 5 Frekuensi .............................................
.............................................
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− %enggunaan sa"un .......................................
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• !eramas 5 Frekuensi .......................................
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−
%enggunaanshamp&&
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• G&s&k gigi 5 Frekuensi .......................................
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− %enggunaan &d&l .......................................
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.......
• Ganti "au 5 Frekuensi .......................................
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• Mem&t&ng kuku 5
Frekuensi
.......................................
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.......• !esulitan .......................................
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.......
• 4saha yang dilakukan .......................................
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