Professional Documents
Culture Documents
ASUHAN KEPERAWATAN
PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
Tanggal pengkajian : ...................................
Tanggal masuk : ...................................
Ruangan : ...................................
Identitas
a. Nama : .......................................................................................
b. Tanggal lahir/umur : .........................................................................................
c. Jenis kelamin : ..........................................................................................
d. Agama : .........................................................................................
e. Suku : .........................................................................................
f. Diagnosa medis : .........................................................................................
g. Penanggung jawab : ..........................................................................................
2. Orang Tua/ Penanggung Jawab
a. Nama : ........................................................................................
b. Hubungan dengan klien :
c. Suku : ........................................................................................
d. Agama : ........................................................................................
e. Alamat : ........................................................................................
f. No. telepon : ........................................................................................
B. Riwayat Klien
1. Riwayat penyakit klien sebelumnya :
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2. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) :
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3. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan, dll) :
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4. Riwayat imunisasi (lengkapi)
Hepatitis B I BCG
Hepatitis B II Hepatitis B III
Polio I Polio II
Polio III Polio IV
DPT I DPT II
DPT III Campak
LAINNYA,sebutkan..............................
5. Riwayat alergi :
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6. Riwayat pemakaian obat-obatan :
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7. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):
Motorik halus :
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Motorik kasar :
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Bahasa :
..........................................................................................................................................
..........................................................................................................................................
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Personal sosial :
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C. Riwayat Kesehatan Keluarga
1. Riwayat penyakit dalam keluarga:
...................
........................................
2. Genogram
Keterangan gambar :
: laki-laki : klien
: perempuan : meninggal
: tinggal dalam satu rumah
c. Vital sign
Capillary
Tanggal TD Nadi RR Suhu
refill
d. Kepala
Inspeksi
Palpasi
e. Mata
Inspeksi
Palpasi
f. Hidung
Inspeksi
Palpasi
g. Mulut
Inspeksi
Palpasi
h. Telinga
Inspeksi
Palpasi
i. Leher
Inspeksi
Palpasi
j. Paru-paru
Inspeksi
Palpasi
Perkusi
Auskultasi
k. Jantung
Inspeksi
Palpasi
Perkusi
Auskultasi
l. Abdomen
Inspeksi
Auskultasi
Perkusi
Palpasi
m. Genitalia
Inspeksi
n. Ekstremitas atas
Kanan Kiri
Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas