SEKOLAH TINGGI ILMU KESEHATAN

BAITURRAHIM JAMBI
PROGRAM STUDI SI KEPERAWATAN
Jl. Prof M Yamin SH,MH No. 30 Lebak Bandung Tlp. 0741-60639 Fax. 668928 Jambi 36129

RIWAYAT KEPERAWATAN
Tanggal Masuk RS
Jam Masuk RS
Ruangan / Kelas
Nomor Kamar
Nomor Registrasi
Diagnosa
I. PENGKAJIAN (Assesment)
A.
Pengumpulan Data
1. Biodata
Nama Pasien
a. Tempat / tgl Lahir
b. Jenis kelamin
c. Status Marital
d. Agama / Kepercayaan
e. Suku / Bangsa
f. Bahasa yang dipakai
g. Pendidikan Terakhir
h. Pekerjaan
i. Alamat
j. Nama / Suami / Istri
k. Tanggal/ jam pengkajian

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2. Riwayat Kesehatan
a. Keluhan Utama ( Chief Complain )
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a. Riwayat kesehatan Masa kini sekarang (PQRST)
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b. Riwayat kesehatan Masa lalu
Penyakit yang pernah di alami
Alergi Makanan/Obat
Kebiasaan makan Obat

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 Kebiasaan Merokok / Minum

Operasi yang pernah dijalani
c. Riwayat kesehatan Keluarga
Susunan anggota keluarga
(genogram 3 generasi)
Penyakit yang pernah di derita
Anggota keluarga
Penyakit yang di alami
Anggota keluarga

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d. Kebiasaan sehari-hari sebelum masuk RS ( 3 bulan terakhir )

Pola makan
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Pola minum
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Pola BAK
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Pola BAB
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Pola mandi
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Pola sikat Gigi
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Kebiasaan memotong kuku
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Pola keramas rambut
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Kebiasaan ganti pakaian
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Pola istirahat tidur siang & malam : .........................................................................
Kebiasaan Olah raga
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Kebasaan rekreasi
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Makanan kesukaan
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Minuman kesukaan
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3. Data Biologis di RS
a. Keadaan Nutrisi
Pola makan
Nafsu makan
Diet
Pantangan
Alergi makanan
Pola minuman
Keluhan lain
b. Eliminasi
Frekuensi BAK /24 jam
Pola BAK
Warna Urine
Keluhan Lain
Frekuensi BAB/ 24 jam
Pola BAB
Warna tinja
Konsistensi Tinja
Keluhan Lain
c. Istirahat dan tidur
Tidur Siang
Tidur Malam

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 Kebiasaan sebelum tidur

Keluhan lain
d. Personal Hygiene
Pola mandi
Pola sikat Gigi
Pola keramas rambut
Kebiasaan mengganti pakaian
Kebiasaan memotong Kuku
Lain-lain
1. Pemeriksaan FisikTanda-tanda Vital
T/D
Nadi
R.R
Suhu
2.

3.

Keadaan Umum
Kesan Umum
Kesadaran
Tinggi badan / berat badan
Ciri-ciri tubuh
Kepala
Struktur kepala
Rambut/Distribusi/Kondisi
Kulit kepala
Lain-lain
a. Telinga
Struktur
Fungsi pendengaran
Uji pendengaran
Cerumen
Cairan telinga
Alat bantu dengar
Lain-lain
b. Hidung
Struktur
Secret Hidung
Fungsi penciuman
Epistaxis
Polip
Keluhan lain
c. Mata
Schlera
Konjungtiva
Pupil
Refleks kornea
Ketajamam Penglihatan
Keluhan Lain

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4.

d. Mulut
Keadaan Bibir
Keadaan gigi
Keadaan Lidah
Fungsi Pengecapan
Fungsi Pengunyah
Mukosa Mulut
Tonsil
Keluhan Lain
Leher
Keadaan Leher
Kelenjer Tiroid
Kelenjer Limfenoid
Keluhan Lain

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5.

Dada
Bentuk dada/struktur
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Retraksi dada
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Buah dada
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Lain-lain
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a. Paru-paru/Pernafasan
Pola Nafas
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Irama Nafas ( inspirasi/ekspirasi): .......................................................................
Penggunaan Aksesories/Organ ...........................................................................
Bantu Pencernaan
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Vocal Fremitus
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Bunyi Nafas
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Lain-lain
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b. Jantung / Cardiovaskular
Ukuran/batas jantung
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Iktus Kordis
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Bendungan Vena
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Pengisian Pembuluh darah
Kafiler
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Bunyi Jantung
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Keluhan Lain
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6.

Perut / Abdomen
Bentuk abdomen
Nyeri efigastrum
Peristalistik Usus
Ukuran Hevar
Limfa
Nyeri tekan / Apendiks
Lain-lain

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7.

8.

9.

Status Neurologis
Tingkat Kesadaran ( GCS)
Motorik (6), Eye (4), Verbal (5)
Orientasi Waktu,Orang, Tempat
Gangguan Motorik (Kelumpuhan)
Lain-lain

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Perasaan terhadap Rangsangan

Nyeri
Suhu
Perabaan
Tekan
Tusukan

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Kulit
Kelainan Warna Kulit
Turgor
Lesi
Keadaan Kulit
Kelainan Lain

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10. MuskoloSkletal
Kekuatan Otot
Tonus Otot
Kecacatan
Nyeri
Trauma
Keterbatasan pergerakan (ROM)
Lain-lain

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11. Sistem Reproduksi Kelamin

Siklus Menstruasi
Keluhan saat Menstruasi
Alat konstrasepsi yang di pakai
Pemeriksaan Usap Vagina
Buah Dada
Keluhan lain
Keadaan Penis / Scrotum
Keluhan kemampuan seksual
Pemeriksaan Sperma
Keluhan Lain

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e. Aktivitas Sehari-hari
Dapat menolong diri sendiri
Sebagian di tolong orang lain
Semua di tolong orang lain

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f.

Hasil pemeriksaan Penunjang

Laboratorium
: - Darah

- Fecces

- Sputum

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Pemeriksaan Sinar X

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Pemeriksaan EKG

USG

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g. Program Pengobatan
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h. Catatan Tambahan
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i.

Data Psikologis
Persepsi terhadap penyakit
Suasana Hati/raut wajah/ sikap

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j.

Perkembangan mental
Karateristik
Daya konsentrasi
Kepekaan terhadap lingkungan
Sosialisasi
Mekanisme Koping
Konsep diri
Stressor (Penyebab stress)

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Data Spiritual
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k. Data Sosial
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ANALISA DATA
No.

DATA

PENYEBAB

MASALAH

NAMA PASIEN
NO. REGISTRASI
TANGGAL
NCP
NO

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Diagnosa Keperawatan

Tujuan

Intervensi

NAMA PASIEN
NO. REGISTRASI
TANGGAL
No.

Tanggal/Bulan/
Jam

CATATAN PERKEMBANGAN
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Diagnosa Keperawatan

Catatan Keperawatan
(SOAP)

Paraf