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FORMAT PENGKAJIAN
Nama Mahasiswa : Arif SoeprijonoNIM : 0960084Ruangan :……………………………………….Tanggal Pengkajian :…………………… Jam …………………
IDENTITAS
Nama Pasien :……………………..Umur :…………………….. Jenis Kelamin :……………………..Suku Bangsa :…………………….Pekerjaan :…………………….Pendidikan :…………………….Alamat :……………………..Tanggal MRS :…………………….Diagnosa Medis :……………………..
KELUHAN UTAMA :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
RIWAYAT KESEHATAN :1. Riwayat Kesehatan/Penyakit sekarang :
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........................................................................................................................Riwayat Kesehatan/Penyakit dahulu :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Riwayat Kesehatan/Penyakit keluarga : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Genogram :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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POLA FUNGSI KESEHATAN :1. Pola penatalaksanaan kesehatan / persepsi sehat
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.........................................................................................................................Masalah Keperawatan :...........................................................................................................................................................................................................................................................................................................................................................................
2. Pola Nutrisi................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................
3. Pola Eliminasi
Eliminasi Alvi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Eliminasi Uri........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................
4. Pola Istirahat dan tidur....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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5. Pola Aktifitas........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :........................................................................................................................................................................................................................................................................................................................................................................
6. Pola kognitif – perseptual – keadekuatan alat sensori
a. Penglihatan, perasa, pembau........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................b. Kemampuan bahasa, belajar, ingatan dan pembuatan keputusan........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan:........................................................................................................................................................................................................................................................................................................................................................................
7. Pola persepsi dan konsep diri
a. Gambaran diri ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b. Harga diri ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c. Ideal diri ........................................................................................................................................................................................................................................................................................................................................................................d. Peran ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
e. Identitas diri ........................................................................................................................
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........................................................................................................................Masalah Keperawatan :........................................................................................................................................................................................................................................................................................................................................................................
8. Pola Reproduksi Seksual........................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9. Pola hubungan peran ........................................................................................................................
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........................................................................................................................Masalah Keperawatan :........................................................................................................................................................................................................................................................................................................................................................................
10. Mekanisme Koping........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :........................................................................................................................................................................................................................................................................................................................................................................
11. Pola tata nilai dan kepercayaan ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PEMERIKSAAN FISIKStatus kesehatan umumKesadaran :
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........................................................................................................................TTV : Suhu : ...............................................................................
TD : ...............................................................................RR : ...............................................................................Nadi : ..............................................................................
PEMERIKSAAN HEAD TO TOE
1. Kepala dan Leher a. Kepala........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................b. Muka ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................c. Mata ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................d. Telinga ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................e. Hidung ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................f. Mulut dan faring........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................g. Leher ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Thorak a. Inpeksi........................................................................................................................
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........................................................................................................................b. Palpasi ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................c. Perkusi ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................d. Auskultasi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Abdomen a. Inpeksi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b. Palpasi ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c. Perkusi ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
d. Auskultasi.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Inguinal, genital dan Anus........................................................................................................................................................................................................................................................................................................................................................................
5. Integumen................................................................................................................................................................................................................................................
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........................................................................................................................6. Muskuloskeletal neurologis
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........................................................................................................................7. Neurologis
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Refleks : Fisilogis
Patologis
PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium Tanggal : .............................., Jam : .......................
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Dextra Sinistra
Triceps\
Dextra Sinistra
Biceps\
Dextra Sinistra
Achiles\
Dextra Sinistra
Knee
Dextra Sinistra
Oppenheim\
Dextra Sinistra
Babinski\
Dextra Sinistra
Chadok
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PEMERIKSAAN HASIL NILAI NORMAL
2. Pemeriksaan Laboratorium Tanggal : .............................., Jam : .......................
PEMERIKSAAN HASIL NILAI NORMAL
3. Pemeriksaan Laboratorium Tanggal : .............................., Jam : .......................
PEMERIKSAAN HASIL NILAI NORMAL
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Pemeriksaan Radiologi................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
1. Pemeriksaan Lain – lain................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Terapi ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
DAFTAR MASALAH KEPERAWATAN
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Surabaya,
Mahasiswa
Arif Soeprijono Nim : 096 0084
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