You are on page 1of 13

A.

PENGKAJIAN

I. IDENTITAS PASIEN PENANGGUNG/SUAMI
Nama : ……………… Nama : ………...……
Umur : ………...…… Umur : ………...……
Pendidikan : ………...…… Pendidikan : ………...……
Pekerjaan : ………...…… Pekerjaan : ………...……
Status perkawinan : ………...…… Alamat : ………...……
Agama : ………...…… Hub.dgn Klien: ………...……
Suku : ………...……
Alamat : ………...……
No. CM : ………...……
Tanggal MRS : ………...……
Tanggal pengkajian : ………...……
Sumber informasi : ………...……

II. RIWAYAT MASUK RUMAH SAKIT
A. Keluhan Utama (Saat MRS dan Sekarang)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
B. Riwayat Penyakit Sekarang
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

............ ........ Riwayat Menstruasi:  Menarche: Umur .................... tahun C......................................  Keluhan : ...................................... .................................................................................................................................. ........................................................... ... ............................................................................................................................... persalinan................. .............................................................................................................................................................................. III........................................................................................................................................................... Lamanya: ............................................................................................ .............................................. Riwayat kehamilan.......................................... tahun Siklus: Teratur ( ) Tidak ( )  Banyaknya: ....... nifas yang lalu: Anak ke Kehamilan Persalinan Komplikasi Nifas Anak Umur Jenis No Tahun Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan BB Pj Kehamilan kelamin ................................................................................ ............... ........................................................................................... RIWAYAT OBSTETRI DAN GINEKOLOGI A.............................................................................. B...................................... kali Lama: ..................... Riwayat Pernikahan:  Menikah: ................... ..........................................  HPHT : ..........................................................................

............................................................................... .................................................................................................................................................................................................. ......................................... ................................................. Pemeliharaan dan Persepsi Terhadap Kesehatan ................................................. ......... Riwayat Keluarga Berencana:  Akseptor KB : Jenis: ............. .................................................................................................................................................................................................................. Nutrisi/Metabolik ..................................................................................... ..................... ............................................................................................................................................................................................................................................................................................. Lama: ..... .......................................................................................................................................................................................................................................................................................................................... E......................................................................................................................... ............................................................................................................................ 2....................................... .......................... ................. ................................................................ ......................................... .................... .............................................................................................................................................................. IV..................................................................................................... .......................................................................... .............................................................................................................................................................................................................................................. .  Masalah : ........................................... Riwayat Penyakit Klien dan Keluarga .............................. .............................................................................................................................................................................................D...................................... .......................................................................................................................................................................................................................................................................................................................................................................................................... ........... POLA FUNGSIONAL KESEHATAN 1............................. ..............................................

..... ....................................................................................................................................................................................................................................................................................................... .. .............................................. Oksigenasi: .................................................................................................... ....... 5............ .......................................................................................................................... ............................................................................................ .................................................................................. ........................................................ ................................................................................................................................................................. Pola Eliminasi .................................................................................................................................................................................... ............................... ..................... Keterangan: .............................................................. ........................................................................................................ .................................................................................................................... .................................................... Pola Aktivitas dan Latihan Kemampuan perawatan diri 0 1 2 3 4 Makan/minum Mandi Toileting Berpakaian Mobilisasi di tempat tidur Berpindah Ambulasi ROM 0: mandiri.................................................................................................................................................................................. .............................................................................................................................................................................................................. 3: dibantu orang lain dan alat................................................................... ..................................................................................................................................................................................................................................... 2: dibantu orang lain............................................ .................................. 1: alat bantu............................................................................................................... 4: tergantung total.......................................................................................... .... 4.................................................................................................................................................................................................................................. 3....................................................................................... ........ .................

....................................................................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................................................................................................... 7..................................................................................................................................................................................................................................... ..................................................................................................................................................................................... Pola Perseptual .......................................................... Pola Tidur dan Istirahat ........................................................................................................................................................................................................................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................ ........................................................................................................................................................................................................................................................................ .......................................... ............................. .................................................................... ............................................................................................................................... ...................... ........................................................................................................................................................................ ........................................................................................................................................................................................ ..................................... ............................................................................................ .................................................................................... ................................ .... ................................. ................ ......................... ............................................................................................ ............................................................................... .................................................... ...................................................................................... 6................................................................................ ...................................................................... ..................................................................... ................................................................................................................................................... Pola Persepsi Diri ................................................................................................ .......................................................... .................................................................................................................................... .................... 8................................................

............ ................................................................................................................................... .......... .................................................. ...................................................... ....................... ......................................................... ........................................................................................................................................................................... ........................................ ......... .............................................................................................................................. ........ Sistem Nilai dan Keyakinan ................................ ............................. ............... Pola Seksual dan Reproduksi ............................................................ ............................................................................... 10.................................................................................................................................................................................................................... ............................................................ .................................... .............................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................... ............................................................................................................................................................... Pola Manajemen Koping Stress ..................................................................................................................................................................................................................................................................................................................................................... 12... .......................................................................................................................... ........................................ ............................................................................ ....................... ..................................................................................................................................................................... ............................................................................................................................. ...... Pola Peran-Hubungan .....................................................................................................................................................9..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................. 11.........................................................................................................................................................

........................... Tingkat kesadaran : ...............  Palpasi ............................................................................................................................................................................................ .............................................. cm B....... Head to toe 1.................................................................................................... 2.................................... ........................................................................................................................kali/menit RR: ....................................................... kg TB: .....................................  Palpasi ................................................................................................ .................................... ........................................... . Kepala Wajah  Inspeksi ..................................................0C BB: ....................................................................................................................................................................................................................................................mmHg N: .................................................. cm LILA: .................. Tanda-tanda vital : TD: ............................................................................................ PEMERIKSAAN FISIK A......................................................................................................................... ........................................................................................................... Keadaan Umum GCS : .......................................................................... Mata  Inspeksi .......................................................... ............................................................................................................. ................................................................................................. ..............................kali/menit S: ........................ V........................................................................ ............................................................................... ...... ....................................

.................................... b...........................................................................................................................  Perkusi ......... Jantung  Inspeksi .........................................................  Palpasi ....................................................................................................... ............................... .............................................................................................. .......................................................... 3........................  Palpasi ................................................................................................. .............. .......................................................................................... ..................................................... ......................................................................................................................... Dada a..................................................... Payudara  Inspeksi Areola: ................................................................ ............................................................................................................................................................................................ ........................................................................ ................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Leher  Inspeksi ............. ................. Puting: Menonjol ( ) Tidak ( ) Tanda dimpling/retraksi: .............................................................. Adanya nodul : ........................................................................ ..................................................................................  Palpasi Pengeluaran ASI: .............. ...................................................................................................................................................................... 4..........................................................................................................................................................................................................

................................................................ ................................................................ ..................... ...................................................................  Auskultasi .................................................................................................................... ...........................................................................................................................................................................................................................  Palpasi .............................. c............................................. .................................................................. ......................................................................................................................................................................................................................................................................................... ............. ........  Perkusi .............................................................. .........................................................  Perkusi ................................................................ ..................... ...................................................................................... Abdomen  Inspeksi ................................... ................................................................................................  Auskultasi ............................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................. . Paru-paru  Inspeksi ................................................ 5...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ....................................................... .....................................................................

.................................................................................................................................................................................................................................................... 6............................................................................................................................................................................................................  Auskultasi .... ....... Kekuatan Otot ............................................................................................................................................................................ Tonus ...... ............... .......................................................................................................................  Karakteristik: .................................................................................................................................................................. 7...........  Keputihan : ..................................................................................................................................................................................................... ........................................................................................................................................................................................................................ Varises : .......... ........................................................................................................ .................................  Hemoroid : ................................. .................................................  Perdarahan : ................................................................................................. ................................................................................ Genetalia dan Perineum  Kebersihan : ....................................................................................... .......................................................................... .................................................................................  Palpasi .............................................................................  Perkusi .............................. ............................................................................................................................... Ekstremitas  Atas Oedema : ............................................................................................................................ ................................ CRT : ........................................................................................................................................................................................................................................................

............................................................................................................................................................................ VI......................................................................................................................................................................................... ................................................................. CRT : ..... ............................................................................................................................................................................................................................................................................................................................................................................................................................. Kekuatan Otot: ............. DATA PENUNJANG  Pemeriksaan Laboratorium No Komponen Hasil Satuan Nilai Normal Interpretasi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 .............................................. ........................................................... ............... ......................... ............ ........................................................................................................................................................ Tonus: ............................................................................................................................................................................................................................. ............................................................................................ ..................................... Varises : ............................................  Bawah Oedema : ............................................................................................................. Pemeriksaan Reflek: ..............................................................................................................

17 18 19  Pemeriksaan Radiologik ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… VII. DIAGNOSA MEDIS ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… VIII. PENGOBATAN ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… .