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RM :
Nama :
Jenis Kelamin :
Tanggal Lahir :
(Mohon diisi atau tempelkan stiker)
RAWAT INAP
ASESMEN KEPERAWATAN
(dilengkapi dalam waktu 2 jam pertama pasien masuk ruang rawat inap)
Tanggal Masuk Pukul : Unit Kerja :
PEMERIKSAAN FISIK
1. Kesadaran :
Compos Mentis Somnolen
Sopor Koma
TD : ______ mmHg N : ______ x/menit RR : ______ x/menit S : ______ °C
2. Gastrointestinal :
Keluhan Tidak Ya. Jika ya, Sebutkan ........................................................................................................................................................
Pembatasan makanan, sebutkan ........................................................................................................................................................................
Gigi palsu Ya, gigi atas / gigi bawah (lingkari salah satu / keduanya) Tidak
Mual Ya, Tidak
Muntah Ya, Tidak BB : ................... Kg TB : ................... Cm Lingkar Kepala Anak : ................... Cm
3. Neurosensori :
a. Pendengaran : Normal Tidak Normal, Sebutkan .....................................................................................................................
b. Penglihatan : OD OD
Visus .............................................. ..............................................
Pergerakan .............................................. ..............................................
Alis Mata .............................................. ..............................................
Palpebra Superior .............................................. ..............................................
Palpebra Inferior .............................................. ..............................................
Kornea .............................................. ..............................................
Iris .............................................. ..............................................
Konjungtiva Bulbi .............................................. ..............................................
Sekret .............................................. ..............................................
Tekanan Bola Mata
Pupil - Reflek .............................................. ..............................................
- Ukuran .............................................. ..............................................
- Isokor .............................................. ..............................................
Bilik Mata Depan
- Hifema .............................................. ..............................................
- Hipopion .............................................. ..............................................
Lensa .............................................. ..............................................
4. Eliminasi :
a. Defekasi Normal Tidak Normal, Sebutkan ...........................................................................................................................
b. Miksi Normal Tidak Normal, Sebutkan ...........................................................................................................................