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

PROGRAM STUDI DIII KEPERAWATAN

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

FORMAT PENGKAJIAN
KESELAMATAN-KEAMANAN-KENYAMANAN

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
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b. Saat Pengkajian
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2. Riwayat Penyakit Sekarang :
...............................................................................................................................................
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...............................................................................................................................................
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 3. Riwayat Penyakit Dahulu :
...............................................................................................................................................
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4. Riwayat Penyakit Keluarga :

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5. Genogram :
Ket :....................................

III. POLA FUNGSI KESEHATAN :

a. Pola Persepsi dan Tata Laksana Kesehatan
........................................................................................................................................
........................................................................................................................................
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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
Waktu Senggang
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

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........................................................................................................................................
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P:

Q:

R:

S:

T:

IV. PEMERIKSAAN FISIK

1. Keadaan
Umum :............................................................................................................
Kesadaran :.....................................................................................................................
Suhu :...............................oC TB :................................cm
RR :...............................x/mnt BB saat ini :..........................Kg
TD :...............................mmHg BB Ideal :...........................Kg
Nadi :...............................x/mnt

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
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10.Pemeriksaan Neurologis
Kesadaran……………………………………………………………………………………….....

Meningeal Sign…………………………………………………………………………………....

Refleks
 Fisiologis…………………………………………………………………………………....

 Patologis…………………………………………………………………………………....

Pemeriksaan Saraf Kranial (I-XII)

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V. Pemeriksaan Diagnostik (cantumkan tanggal pemeriksaan)
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VI. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)

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VII. Terapi (disertai dosis tiap pemberian)

Oral
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Parenteral
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………………,…………………..20…
Mahasiswa

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NIM…………………………