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FORM PENGKAJIAN Nama:…………………. MA KDK TAHUN 2012/2013 NIM :…………………. BiodataPasien Nama :………………………….. Umur :………………………….. Alamat :………………………….. Pendidikan :………………………….. Pekerjaan :………………………….. RiwayatKesehatan 1. KeluhanUtama ……………………………………………………………………………………………………………………………………. 2. KeluhanTambahan ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. 3. RiwayatPenyakitDahulu ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. 4. RiwayatPenyakitSekarang ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. 5. RiwayatPenyakitKeluarga ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. PemeriksaanFisik Kesadarankualitatif :…………………………. Tanda-tanda vital : TD:……………SB:………….N:………….R Pemeriksaanfokus ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. PolaPengkajianFungsional 1. Polapersepsikesehatan ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. 2. Polanutrisi metabolic ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………. 3. Polaeliminasi 1
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FORM PENGKAJIAN Nama:.MA KDK TAHUN 2012/2013 NIM :.BiodataPasienNama :..Umur :..Alamat :..Pendidikan :..Pekerjaan :..RiwayatKesehatan1. KeluhanUtama.2. KeluhanTambahan... RiwayatPenyakit!ahulu..". RiwayatPenyakit#ekaran$..%. RiwayatPenyakitKeluar$a..Pemeriksaan&isikKesadarankualitati' :.Tanda(tanda *ital : T!:#B:.N:.RPemeriksaan'okus..PolaPen$kajian&un$sional1. Pola+erse+sikesehatan......12. Polanutrisi metaboli,...... Polaeliminasi.......". Polaakti*itas-latihan........%. Polaistirahat-tidur.....2... Polako$niti'-+erse+sional....../. Pola+erse+sidiri-konse+diri......0. Pola+eran-hubun$an......1. Pola#eksualitas-re+roduksi....3..12. Polako+in$-Toleransistrees......11. Polanilai-ke+er,ayaa......Analisa !ata#ym+tom-#i$n 3tiolo$i Problem!ia$nosake+erawatan1..2.4...Perencanaan(HANYA DIAGNOSA PRIORITAS PERTAMA)NO DIAGNOSA TUJUAN INTERVENSI RASIONAL5
