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U N I V E R S I T A S B O N D O W O S O

PR OGR A M S TUD I D III K E P ER AWATA N


Jalan Chairil Anwar No.3B Tlp/Fax. (0332) 433015 Bondowoso

FORMAT PENGKAJIAN
AKTIVITAS DAN MOBILITAS

Rumah sakit :………………………………………………………………………………..


Ruangan :………………………………………………………………………………..
Tgl/Jam MRS :………………………………………………………………………………..
Dx. Medis :………………………………………………………………………………..
No. Register :………………………………………………………………………………..

Pengkajian Oleh :..............................................................................................................


Tgl/Jam pengkajian :..............................................................................................................

I. BIODATA PENANGGUNG JAWAB


Nama Klien Nama :……………………........
:..............................................................................................................
Umur Umur :………………………….
:..............................................................................................................
Jenis Kelamin Pendidikan :………………………….
:..............................................................................................................
Pendidikan Pekerjaan :………………………….
:..............................................................................................................
Pekerjaan Alamat :………………………….
:..............................................................................................................
Agama Hubungan dengan klien
:..............................................................................................................
Gol. Darah Suami/ Istri/Orangtua/…………………..
:..............................................................................................................
Alamat :..............................................................................................................

II. RIWAYAT KESEHATAN


1. Keluhan Utama :
a. Saat MRS
.........................................................................................................................................
.........................................................................................................................................
b. Saat Pengkajian
.........................................................................................................................................
.........................................................................................................................................
2. Riwayat Penyakit Sekarang :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
3. Riwayat Penyakit Dahulu :
...............................................................................................................................................
...............................................................................................................................................
..............................................................................................................................................
Trauma masa lalu/ fraktur.....................................................................................................
Pembedahan..........................................................................................................................
4. Riwayat Penyakit Keluarga :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
5. Genogram :
Ket :.....................................................

III. POLA FUNGSI KESEHATAN :


a. Pola Persepsi dan Tata Laksana Kesehatan
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
b. Pola Nutrisi
Macam Sebelum Sakit Saat sakit
Makan
 Frekuensi ............................... ................................
 Jenis ............................... ................................
 Porsi ............................... ................................
 Keluhan ............................... ................................

Minum
 Frekuensi ............................... ................................
 Jenis ............................... ................................
 Jumlah ............................... ................................
 Keluhan ............................... .................................

c. Pola Eliminasi
Kebiasaan BAB
Keterangan Sebelum Sakit Saat Sakit

 Frekuensi ....................................... .......................................


 Jumlah ....................................... .......................................
 Bau ....................................... .......................................
 Warna ....................................... .......................................
 Konsistensi ....................................... .......................................
....................................... .......................................
 Keluhan
Kebiasaan BAK
Keterangan Sebelum Sakit Saat Sakit

 Frekuensi ....................................... .......................................


 Jumlah ....................................... .......................................
 Bau ....................................... .......................................
 Warna ....................................... .......................................
 Keluhan ....................................... .......................................

d. Pola Aktivitas dan kebersihan diri


Keterangan Sebelum Sakit Saat Sakit
Mobilitas Rutin
Mobilitas di atas tempat tidur
Waktu Senggang
Berdiri-berjalan
Mandi
Berpakaian
Berhias
Toileting
Makan-minum
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total

e. Pola Istirahat-Tidur
Keterangan Sebelum Sakit Saat Sakit
Lama tidur siang
Lama tidur malam
Pengantar tidur
Gangguan tidur

f. Pola Kognitif dan Persepsi Sensori


........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

IV. PEMERIKSAAN FISIK


1. Keadaan
Umum :............................................................................................................
Kesadaran :.....................................................................................................................
Suhu :...............................oC
No Tanda-Tanda Vital Saat Istirahat Setelah Melakukan
Aktivitas

1 Tekanan Darah ........................................ ..................................

2 Nadi ........................................ ..................................

3 RR .......................................... ..................................

TB :................................cm
BB saat ini :................................Kg
BB Ideal :.................................Kg

2. Kepala
 Rambut :………………………………………………………………………….......
 Wajah : ……………………………………………………………………….........
 Mata : ……………………………………………………………………….........
 Hidung :………………………………………………………………………….......
 Mulut :………………………………………………………………………….......
 Gigi :………………………………………………………………………….......
 Telinga :………………………………………………………………………….....

3. Leher
I.........................................................................................................................................
P........................................................................................................................................

4. Payudara dan Ketiak


I..........................................................................................................................................
P........................................................................................................................................

5. Dada
Paru-Paru
I……………………………………………………………………………………………………
P........................................................................................................................................
P........................................................................................................................................
A………………………………………………………………………………………………….
Jantung
I……………………………………………………………………………………………………
P........................................................................................................................................
P........................................................................................................................................
A………………………………………………………………………………………………….
6. Abdomen
I…………………………………………………………………………………………………..
A…………………………………………………………………………………………………
P…………………………………………………………………………………………………
P………………………………………………………………………………………………….

7. Ekstremitas
Atas
I…………………………………………………………………………………………………..
P………………………………………………………………………………………………….
Gerakan Sendi…………………………………………………………………………………
…………………………………………………………………………………………………….
Kekuatan Otot…………………………………………………………………………………
Bawah
I………………………………………………………………………………………………….
P…………………………………………………………………………………………………
Gerakan Sendi………………………………………………………………………………..
………………………………………………………………………………………………….
Kekuatan Otot…………………………………………………………………………………

8. Tulang Belakang/ Punggung-pinggang


I ……………………………………………………………………………………………………
P…………………………………………………………………………………………………..

9. Anus – Genetalia
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..

10. Pemeriksaan Neurologis


Kesadaran………………………………………………………………………………………
Meningeal Sign…………………………………………………………………………………
Refleks
 Fisiologis………………………………………………………………………………….....
 Patologis………………………………………………………………………………….....
Pemeriksaan Saraf Kranial (I-XII)
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..

V. Pemeriksaan diagnostik (cantumkan tanggal pemeriksaan)


........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

VI. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)


........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

VII. Terapi (disertai dosis tiap pemberian)


Oral
........................................................................................................................................
........................................................................................................................................
Parenteral
........................................................................................................................................
........................................................................................................................................

………………,…………………..20…..
Mahasiswa

( )
NIM…………………………

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