PENGKAJIAN DASAR KEPERAWATANNama Mahasiswa : Tempat Praktik : NIM : 12507012181130 Tgl. Praktik : A. Identitas KlienNama :..................................... No. RM :Usia : ..........tah! Tgl. Masuk :Jenis kelamin :..................................... Tgl. Pengkajian :Alamat :..................................... "m#er i!$ormasi:.....................................No. telepon :..................................... Nama klg. %ekat &g #isa %ih#!gi:Status pernikahan :.....................................Agama :..................................... "tats :Suku :..................................... Alamat : Pendidikan :..................................... No. telepon :Pekerjaan :..................................... Pendidikan :'ama #erker(a :..................................... Pekerjaan : B. Status kesehatan Saat Ini1. )elha! tama : sesak* irama %a! $reke!si per!a$asa!!&a me!i!gkat serta#a!&ak me!gelarka! %ahak2. 'ama kelha! : 2 hari ..........................................................................................3. )alitas kelha! : ....................................................................................................4. +aktor pe!,ets : memp!&ai peliharaa! seekor k,i!g 5. +aktor pem#erat : ),i!g %i #iarka! #erkeliara! %i rmah!&a setiap hari6. Upa&a &g. telah %ilakka! : ----------............................................................7. )elha! saat Pe!gka(ia! : "esak %a! me!gelh gatal %i selrh t#h!&aC. Riwayat Kesehatan Saat Ini.........me!gelh sesak* irama %a! $reke!si per!a$asa!!&a me!i!gkat serta #a!&ak me!gelarka! %ahak* ti%ak ma maka!* me!gelh gatal %i selh t#h!&a.iag!osa me%is: /D.Riwayat Kesehatan Terdahulu1. Pe!&akit &g per!ah %ialami:a. )e,elakaa! 0(e!is 1 wakt2 : /#. 3perasi 0(e!is 1 wakt2 : /,. Pe!&akit: )ro!is : / 4kt : /%. Terakhir maski R" : / 2. 4lergi 0o#at* maka!a!* plester* %ll2:TipeReaksiTi!%aka!4lergi #l k,i!g.................. "esak %a! gatal selrh t#h 3. Im!isasi:0 2 567 0 2 8epatitis0 2 Polio 0 2 6ampak0 2 .PT 0 2 ...............4. )e#iasaa!:9e!is +reke!si 9mlah'ama!&aMerokok /)opi /4lkohol /5. 3#at/o#ata! &g %ig!aka!:9e!is 'ama!&a .osis.............................................. ......................................... ......................................................................................... ......................................... ...........................................E. Riwayat Keluara.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................7:N37R4M0mi!imal 3 ge!erasi* riwa&at pe!&akit kelarga* ta!%ai pasie! %e!ga! ta!%a pa!ah2!. Riwayat "inkunan9e!is Rmah Peker(aa! )e#ersiha! Memelihara k,i!g &a!g %i #iarka! #erkeliara! %i rmah........... 5aha&a ke,elakaa! ................................................ ................................................ Polsi ................................................ ................................................ ;e!tilasi ................................................ ................................................ Pe!,aha&aa! ................................................ ............................................................................ .............................................. ...................................................G.P#la Akti$tas%"atihanRmah Rmah "akit Maka!