Escolar Documentos
Profissional Documentos
Cultura Documentos
ASSESMEN KEPERAWATAN
1. Anamnesa
a. Keluhan Utama :
_________________________________________________________________________________
_________________________________________________________________________________
b. Riwayat Penyakit :
_________________________________________________________________________________
_________________________________________________________________________________
c. Riwayat Alergi :
_________________________________________________________________________________
_________________________________________________________________________________
2. Tanda-Tanda Vital
TD : _______mmHg Pernapasan : ______x/mnt
Nadi : _______x/mnt Suhu : ______ C
3. Antropometri
BB : _______ kg TB : ________ cm LK : __________ cm
KATEGORI 0 1 2
ANGGOTA Posisi anggota gerak Anggota gerak bawah Anggota gerak bawah (lower
GERAK BAWAH bawah (lower (lower ekstremitas) ekstremitas) menendang -
(LOWER ekstremits) normal kaku, gelisah nendang
EXTREMITAS) atau rileks
Lain lain 1
Dalam 24 jam 3
Respon terhadap Dalam 48 jam 2
pembedahan,
sedasi, dan anestesi Lebih dari 48 jam / tidak ada respon 1
_______________________________________
Tanda tangan dan nama jelas
ASESSMEN MEDIS
I. ANAMNESA
1. Keluhan Utama (mulai, lama, pencetus) :
________________________________________________________________________________
________________________________________________________________________________
2. Riwayat penyakit sekarang :
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Riwayat penyakit dahulu (termasuk riwayat operasi) :
_________________________________________________________________________________
_________________________________________________________________________________
4. Riwayat penyakit dalam keluarga :
DM Hipertensi TBC Asthma Hepatitis Jantung
Kelainan darah TAK Lain-lain____________________________
6. Leher
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________
7. Thorax
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
8. Abdomen
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. Genetalia
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
10. Extremitas
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
IV. Pemeriksaan status generalis & status lokalis (inspeksi, palpasi, perkusi, dan auskultasi)
V. Pemeriksaan penunjang:
Radiologi Lab USG EKG Lain-lain_____________________________
____________________________________________________________________________________
____________________________________________________________________________________
VI. Diagnosa
1. Diagnosa kerja :
_________________________________________________________________________________
_________________________________________________________________________________
____________________________________________________________
2. Diagnosa banding :
_________________________________________________________________________________
_________________________________________________________________________________
____________________________________________________________
Tanggal____________________________Pkl_________
Dokter yang Melakukan Pengkajian
___________________________________
Tanda tangan dan nama jelas