Lampiran 1

PENGKAJIAN AWAL

A. Identitas Klien
1. Nama/nama panggilan:

2. Tempat tanggal lahir/usia:

3. Jenis kelamin:

4. A g a m a:

5. Pelaku rawat:

6. Alamat:

8. UPK/Dokter:

9. Diagnosis utama:

10. Diagnosis penyerta/metastase:

B. Identitas Orang Tua/Wali/Pelaku Rawat Lain

Pelaku Rawat Lain
Ibu Ayah Wali
(jika ada)

Nama: Nama: Nama: Nama:

U s i a: U s i a: U s i a: U s i a:

Pendidikan: Pendidikan: Pendidikan: Pendidikan:

Pekerjaan: Pekerjaan: Pekerjaan: Pekerjaan:

A g a m a: A g a m a: A g a m a: A g a m a:

Alamat: Alamat: Alamat: Alamat:

No telp: No telp: No telp: No telp:

C. Identitas Saudara Kandung (jika pasien anak)

No Nama Usia Hubungan Kesehatan

D. Genogram

Keterangan:

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E. Riwayat Kesehatan
Riwayat:

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Kapan awal mengalami penyakit ini? :

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Bagaimana respon klien dan keluarga saat mengetahui penyakit yang diderita ;
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Apa yang dilakukan saat tahu penyakit nya dan yang dilakukan selama sakit :
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Obat-obatan sebelum nya :

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F. PENGKAJIAN FISIK
1. Keadaan umum:
2. Kesadaran:
3. Tanda–tanda vital:
a. Tekanan darah:
b. Denyut nadi:
c. Suhu:
d. Pernapasan:
4. Berat badan:
5. Tinggi badan:
6. Kepala:
7. Lingkar lengan:
8. Rambut & kepala:
Inspeksi:
Palpasi:
Catatan:
9. Mata dan penglihatan
Inspeksi:
Palpasi:
Catatan:
10. Hidung & sinus
Inspeksi:
Palpasi:
Catatan:
11. Telinga dan pendengaran
Inspeksi:
Palpasi:
Catatan:
12. Mulut dan tenggorokan
Inspeksi:
Palpasi:
Catatan:
13. Sistem endokrin
Inspeksi: Palpasi:
Catatan:
14. Thorax dan pernapasan
Inspeksi:
Palpasi:
Perkusi:
Auskultasi:
Catatan:
15. Abdomen
Inspeksi:
Auskultasi:
Perkusi:
Palpasi:
Catatan:
16. Genitalia dan anus
Inspeksi:
Palpasi:
Catatan:
17. Ekstremitas
Ekstremitas atas
Inspeksi:
Palpasi:
Catatan:
Ekstremitas bawah
Inspeksi:
Palpasi
Catatan:
18. Status neurologi
Inspeksi: Palpasi:
Catatan:
 19. Sistem eliminasi
BAB
Konsistensi:
Frekuensi:
Keluhan:
BAK
Warna:
Frekuensi:
Keluhan:

G. Data Penunjang
Laboratorium
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Foto Rotgen, CT Scan, MRI, USG, EEG, ECG

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H. Terapi Saat Ini (ditulis dengan rinci)

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I. Kondisi Psikologis, Sosial, dan Spiritual

Psikologis (pasien dan keluarga)

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 Sosial (pasien dan keluarga)

a. UPK:
b. LSM:
c. Jaminan kesehatan:
d. Penyokong dana:
e. Pendapatan perbulan:
f. Kondisi rumah:
g. Ventilasi rumah:
h. Rumah milik:
i. Keadaan lingkungan:

Keterangan:
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Spiritual (pasien dan keluarga)

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J. Masalah Saat Ini

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K. Tindakan saat Kunjungan

1. Fisik
 Me
dis
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Keperawatan
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Fungsional
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2. Psikologis
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3. Sosial
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4. Spiritual
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L. Tujuan Asuhan
Jangka panjang

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Jangka pendek

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M.Rencana Asuhan
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Hari dan tanggal

pengkajian: Waktu:

Perawat:

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