1.

Pengkajian

A. Biodata
Nama : ...............................................................................
Jenis Kelamin : ...............................................................................
Umur : ................................................................................
Status Perkawinan : ...............................................................................
Pekerjaan : ................................................................................
Agama : ...............................................................................
Pendidikan Terakhir : .................................................................................
Alamat : .................................................................................
No. Register : ..............................................................................
Tanggal MRS : ................................................................................
Tanggal Pengkajian : ..............................................................................
Dx. Medis : ................................................................................

B. Riwayat Kesehatan Klien

1. Keluhan Utama / Alasan Masuk Rumah Sakit :
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Kesehatan Yang Lalu :
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 4. Riwayat Kesehatan Keluarga :
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C. Pola Pengkajian Fungsional
1. Pola Persepsi – Manajemen Kesehatan
No Keterangan Sebelum Sakit Saat MRS

Gambaran
1 kesehatan secara
umum dan saat ini

Alasan kunjungan
2
dan harapan

Gambaran
terhadap sakit,
3 peyebabnya dan
penanganan yang
dilakukan

Kepatuhan
4 terhadap
pengobatan
 Pencegahan atau
5 tindakan dalam
menjaga kesehatan

Penggunaan obat
6
resep dan warung

Penggunaan
produk atau zat
didalam kehidupan
7 sehari-hari dan
frekuensi (
misalnya: rokok
dan alkohol )

Penggunaan alat
keamanan dirumah
8 / sehari-hari, dan
factor resiko
timbulnya penyakit

Gambaran
9
kesehatan keluarga
 2. Pola Nutrisi – Metabolik

No Keterangan Sebelum Sakit Saat MRS

1 Pola makan

2 Intake makan

3 Intake cairan

4 Nafsu makan

Diet dan alergi

5
makanan
6 Kesulitan menelan

7 Mual/muntah

Flukruasi berat
8
badan

3. Pola Eleminasi

No Keterangan Sebelum Sakit Saat MRS

1 Frekuensi BAK

2 Frekuensi BAB

3 Karakteristik BAK
4 Karakteristik BAB

5 Gangguan eliminasi

Penggunaan alat
6
bantu

4. Pola Aktivitas – Latihan

Sebelum Sakit Saat MRS

No Keterangan
0 1 2 3 4 0 1 2 3 4
1 Mandi
2 Berpakaian
3 Perawatan diri
4 Toileting
5 Kontinensia
6 Berpindah
7 Berjalan
8 Makan

Ket : 0 : mandiri, 1: dengan alat bantu, 2 : dibantu orang lain, 3 : dibantu orang dan alat

4 : ketergantungan total
 5. Pola Istirahat – Tidur

No Keterangan Sebelum Sakit Saat MRS

1 Lama tidur

Jam tidur – Jam

2
bangun

3 Kualitas tidur

Kebiasaan sebelum
4
tidur

5 Kesulitan tidur
 6. Pola Kognitif – Persepsi

No Keterangan Sebelum Sakit Saat MRS

Kemampuan
1
penglihatan

Kemampuan
2
pendengaran

Kemampuan
3
penciuman

Kemampuan
4
pengecapan

5 Kemampuan taktil
6 Status mental

7 Daya pikir

8 Fungsi intelektual

9 Status emosional

Kemampuan
10
bahasa
 7. Pola Persepsi Diri

No Keterangan Sebelum Sakit Saat MRS

1 Gambaran diri

2 Harga diri

3 Peran

4 Identitas

5 Ideal diri
 8. Pola Peran dan Hubungan

No Keterangan Sebelum Sakit Saat MRS

Peran dalam
1
keluarga

Sistem
2
pendukung

Pengambilan
keputusan dan
3 penyelesaian
konflik dalam
keluarga

4 Kondisi keuangan

5 Interaksi sosial
 9. Pola Seksualitas – Reproduksi

No Keterangan Sebelum Sakit Saat MRS

Hubungan
1
seksual

Penggunaan alat
2
dan pelindung

Pemenuhan
3 kebutuhan
seksualitas

10. Pola Pertahan Diri (Koping – Toleransi Stress)

No Keterangan Sebelum Sakit Saat MRS

Mekanisme
koping ketika
1
menghadapi
masalah

11. Pola Nilai – Kepercayaan

No Keterangan Sebelum Sakit Saat MRS

Kegiatan
1
keagamaan

Nilai kepercayaan
2
kepada tuhan
D. Pemeriksaan Fisik
1. Kesan Umum / Keadaan Umum :
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2. Tanda-tanda Vital
Suhu Tubuh : Nadi :
…………………… ……………...................
Takanan Darah : Respirasi :
……………….….. ………………………….
Tinggi Badan : Berat Badan :
…………………... ………………………….

3. Pemeriksaan Kepala dan Leher :

1) Kepala dan Rambut
a. Kepala
Inspeksi Palpasi

b. Rambut
Inspeksi Palpasi
c. Wajah
Inspeksi Palpasi

d. Mata
Inspeksi

e. Hidung
Inspeksi Palpasi

f. Telinga
Inspeksi Palpasi
 g. Mulut dan Tenggorokan
Inspeksi Palpasi

h. Leher
Inspeksi Palpasi

2) Pemeriksaan Thorack / Dada :

a.Thorak
Inspeksi Palpasi

b. Paru
Palpasi Perkusi Auskultasi
 c. Jantung
Inspeksi Palpasi Perkusi Auskultasi

3) Pemeriksaan Payudara dan Ketiak :

Inspeksi Palpasi

Payudara

Ketiak
4) Pemeriksaan Abdomen
Inspeksi Auskultasi Palpasi Perkusi

5) Pemeriksaan Pemeriksaan Kelamin dan Daerah Sekitarnya

Inspeksi Palpasi

6) Pemeriksaan Musculoskeletal (Ekstermitas)

a.
Inspeksi Palpasi

b. Kekuatan otot : -------------------------------------------------------------------------------------

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7) Pemeriksaan Kulit dan Kuku
Inspeksi Palpasi

8) Pemeriksaan Neurologi
a. Tingkat Kesadaran (secara aktif ) / GCS :
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b. Fungsi Serebal :
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c. Saraf Kranial :
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d. System Motorik :
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 e. Reflek fisiologis dan patoligis :
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f. System Sensori :
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9) Pemeriksaan penunjang
Hasil Pemeriksaan Laboratorium :
1. Darah Lengkap
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10) Progam terapi :
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E. Analisa Data
No Data Etiologi Problem
F. Diagnosa Keperawatan
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D. Rencana Keperawatan

No Tujuan Kriteria Hasil Intervensi

G. Tindakan Keperawatan

No Hari /
Jam Implementasi TTD
Dx Tanggal
H. Evaluasi Keperawatan

No
Hari/ Jam Evaluasi TTD
Dx Tanggal