Nama Mahasiswa :
Nomor Mahasiswa :
Tempat Praktek :
Tanggal Praktek :
I.Identitas diri klien
Nama Klien :
Tempat Tgl Lahir ;
Umur Klien :
Jenis Kelamin :
Alamat :
Status Perkawinan :
Agama :
Suku :
Pendidikan :
Pekerjaan :
Tanggal MRS :
NO. RM :
Tanggal Pengkajian :
Sumber informasi :
Keluarga yang dapat dihubungi :
Pendidikan :
Pekerjaan :
Alamat :
II. Status Kesehatan Saat ini
1.Keluhan Utama Saat Ini :
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2. Faktor pencetus :
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3. lamanya keluhan :
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4. Timbulnya keluhan :
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5. Faktor yang memperberat :
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6. Upaya yang dilakukan untuk mengatasinya :
Sendiri : __________________________________________________________________
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Oleh orang lain : ___________________________________________________________
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Diagnosa Medik : ____________________________________________________________
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Kesehatan Reproduksi : Kehamilan G P A
| No. Anak | Gg. Kehamil an | Proses Persalin an | Lama Persalin an | Tempat Persalin an | Masa Lah per Salin an | Masalah Nifas Dan laktasi | Masalah bayi | Keadaa An anak Saat ini |
| | | | | | | | | |
Pemeriksaan payudara:______________________________________________________ 
keluhan payudara : ________________________________________________ Pemeriksaan Genetalia : _____________________________________________________ keluhan genetalia :_________________________________________________ Usia menarche : ___________________________________________________________ Usia perkawainan__________________________________________________________ Siklus menstruasi __________________________________________________________ Karakteristik menstruasi ; ___________________________________________ Menopause_______________________________________________________________ ,keluhan yang muncul selama ini _____________________________________ Masalah yang berhubungan dengan kesehatan reproduksi : _________________________ o sejak kapan ______________________________________________________
o sudah dilakukan _________________________________________________
Penbedahan_______________________________________________________________ ________________________________________________________________________
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Pemeriksaan papsmear terakhir________________________________________________ ________________________________________________________________________ .
Pemeriksaan payudara sendiri ; _______________________________________________ ________________________________________________________________________
III. Riwayat Kesehatan Yang Lalu
- Penyakit yang pernah dialami :
- Kanak – kanak : __________________________________________________
- Kecelakaan :____________________________________________________
- Pernah dirawat ___________________________________________________
- Alergi ________________________________________________________________
- Imunisasi : ____________________________________________________________
- Kebiasaan merokok,kopi,obat dan alcohol _____________________________________
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- Obat-obatan :___________________________________________________________
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- Pola Nutrisi :
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___
- Pola eliminasi :
- Buang Air Besar
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- Buang Air kecil
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- Pola Todur dan Istirahat
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- Pola Aktifitas dan Latihan
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- Pola bekerja
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IV. Riwayat Keluarga
Genogram
Riwayat Lingkungan: __________________________________________________________
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Aspek psikososial :
- Pola pikir dan persepsi:
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- Persepsi diri
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- Suasana hati
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- Hubungan/komunikasi
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- Kebiasaan Seksual
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- Pertahanan koping
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- Sistem Nilai dan kepercayaan
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- Tingkat perkembangan
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VII. Pengkajian Fisik
Tanda Vital : Tekanan darah : ________ mmHg
Nadi : __________- x/m
Temperatur : __________ ‘C
Respirasi rate : _________ x/m
Berat Badan : _____ kg , Tinggi Badan : _______ cm
Kepala : ____________________________________________________________________
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Mata :______________________________________________________________________
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Hidung : ___________________________________________________________________
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Mulut dan Tenggorok : ________________________________________________________
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Pernafasan : _________________________________________________________________ __________________________________________________________________
Sirkulasi : __________________________________________________________________
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Nutrisi : ____________________________________________________________________
Eliminasi : __________________________________________________________________ __________________________________________________________________
Genetalia : __________________________________________________________________
Neurosis : __________________________________________________________________ __________________________________________________________________
Muskuloskeletal : ____________________________________________________________
Kulit : _____________________________________________________________________ .
Data Laboratorium
| Tanggal dan jenis pemeriksaan | Hasil pemeriksaan dan nilai normal | Interpretasi |
| | | |
Terapi Medis yang diberikan
| Tanggal | Jenis terapi | Rute terapi | Dosis | Indikasi terapi |
| | | | | |
Hasil pemeriksaan diagnostik lain :
Persepsi Klien terhadap penyakitnya :
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Kesan perawat terhadap klien :
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