Format tertutup

L A M P IR A N 1 4
R S U P N A S IO N A L D R .C IP T O M A N G U N K U S U M O
B ID A N G K E P E R A W A T A N

P E N G K A J IA N A W A L K E P E R A W A T A N
D I R U A N G R A W A T IN A P

R u a n g ra w a t :
N o . R e k a m M e d ik :

1. Nam a : U m ur : A ga m a :
P e n d id ik a n : B a h a s a y a n g d ig u n a k a n :
P e k e rj a a n : S ta tu s p e r k a w in a n : M ,S ,D ,J
Ta n g g a l M a s u k : T g l & j a m p e n g a m b il a n d a t a :

2 . R iw a y a t K e s e h a t a n :
a . R i w a y a t K e s e h a ta n s e k a r a n g :

b . R i w a y a t k e s e h a t a n y a n g l a l u d a n r i w a y a t k e s e h a ta n k e l u a r g a :

3. P e m e r ik s a a n f i s ik / b io lo g is :
~ T . D . .. . . . . . . . . . m m H g , S u h u . .. . . . . . . . . . 0 C , P . . . . . . . . . . . . x / m n t , N a d i . . . . . . . . . . . . . x / m n t , B B . . . . . . . . . . .. K G , T B . . . . . . . . . . . . . C m .
~ K e s a d a ra n : CM A p a t is S o m n o le n t S o p o ru s K o rm a G CS
~ K e p a la : t.a .k m e s o s e fa l a s im e t is h e m a to m a
~ R a m bu t : t.a .k k o to r b e r m in y a k k e rin g ro n to k
~ M uka : t.a .k a s im e t r is b e lls p a ls y t i c fa c i a l l s
k e l a i n a n k o n g e n i ta l
~ M a ta : t.a .k g a n g g u a n p e n g lih a t a n s k lera a n e m is k o n ju n g t iv it is
a n is o k o r m id r ia s is / m io s is t id a k a d a r e a k s i c a h a y a L a i n - l a i n : . . . . . . . .. .
~ T e li n g a : t.a .k be rd e n g un g n y e ri t u li k e lu a r c a ir a n la i n - la in : . . . . . . . . . .
~ H id u n g : t.a .k a s i m e t r is e p i s ta k s i s l a i n - l a i n : . . . . .. . . . .
~ M u lu t : t.a .k s i m e t r is a s im e t r is b ib ir p u c a t
k e l a i n a n k o n g e n i ta l l a i n - l a i n : . . . .. . . . . . . . . . . . . . . . ..
~ G ig i : t.a .k k a r ie s g oy an g ta m b a l g ig i p a ls u la i n - la in : . . . . . . . . . . .
~ Lid ah : t.a .k k o to r m u k o s a k e r in g g e r a k a n a s im e t ir s
~ te n g g o r o k a n : t.a .k fa ri n g m e r a h s a k it m e n e la n t o n s il m e m b e s a r
l a i n - l a i n : . . . . . . . . . .. . . . . .
~ Le h e r : t.a .k p e m b e s a r a n t ir o id p e m b e s a ra n v e n a ju g u la ri s
kaku kuduk k e t e r b a ta s a n g e r a k l a i n - l a i n : . . . . .. . . . . . . . . . . . .
~ Dada : t.a .k a s i m e t r is re tr a k s i ro n c h i ra le s
w h e e z in g s u a r a S 1 /S 2 m u m ur n y e ri d a d a
a r it m ia t a k h ik a r d i b r a d ik a r d i p a lp it a s i
~ In te g u m e n : t.a .k tu r g o r d in g in b u la d e k u b it u s f is t u la pucat
baal R L P o s i t if l a i n - l a i n : . . . . . . .. . . . . . . . . . . . . .
~ E k s t r e m it a s : t.a .k k e k u a ta n o to t k e ja n g tr e m o r p le g i d i. . . . . . . . . . .
p a re s e d i d i. . . . . . . . . . . . k e la in a n k o n g e n it a l in k o rd in a s i l a i n - l a i n : .. . . . . . . .

4 . P o la k e b ia s a a n p a s i e n
~ N u trs i : t.a .k a n o r e k s ia nausea v o m it u s sonde in f u s
d iit
~ E lim in a s i : t.a .k k o n s t ip a s i d ia re pe n d a ra h an o s to m i k a te te r
in k o n t in e n s ia a lv i r e t e n s i u r in e a n u r ia o li g o u r i
~ I s t ira h a t / t id u r : t . a .k in s o m n ia h ip e r s o m n ia l a i n - l a i n : .. . . . . . . . . . . . .
~ A k t i v i ta : t.a .k m a n d ir i t e r g a n t u n g s e b a g ia n t e r g a n tu n g p e n u h la in - la in : . . . . . .
5. Data Psikologis, Sosiologis, dan Spiritual
~ Psikologis : t.a.k gelisah takut sedih rendah diri hiperaktif
acuh tak acuh marah mudah tersinggung lain-lain:.........
~ Sosilogis : t.a.k menarik diri komunikasi
~ Spiritual : perlu dibantu dalam beribadah
lain-lain:.....................................................

6. Data penunjang (EKG, EEG, Laboratorium, Pemeriksaan Radiologi, dan lain-lain).

a. ................................................................................................ ................................................................
b. ................................................................................................ ................................................................
c. ................................................................................................ ................................................................

7. Rumusan Masalah
a. ................................................................................................ ................................................................
b. ................................................................................................ ................................................................
c. ................................................................................................ ................................................................

Jakarta, ...............................20......

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Tanda tangan dan nama jelas perawat primer

NOTE:
Kelebihan: Kekurangan:
1. Lebih efisien waktu 1. Lebih kaku/ tidak fleksibel
2. Lebih sedikit format (biaya) 2. Kurang komprehensif
3. Lebih efektif 3. Data subyektif tidak dapat
4. Sesuai untuk kondisi akut dieksplorasi
5. Lebih terstandar pengisiannya 4. Kurang sesuai untuk
6. Terstruktur dengan baik praktikan keperawatan