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A. PENGKAJIAN
1. Pengumpulan Data
a. Identitas Klien
1) Nama : ......................................................................................
2) Jenis Kelamin : ......................................................................................
3) Umur : ......................................................................................
4) Status Perkawinan : ......................................................................................
5) Pekerjaan : ......................................................................................
6) Agama : ......................................................................................
7) Pendidikan Terakhir : ......................................................................................
8) Alamat : ......................................................................................
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g. Pola Aktifitas Sehari—hari
1) Makan dan Minum
Sebelum MRS : ....................................................................................................
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Ketika MRS : .......................................................................................................
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2) Pola Eliminasi
a. BAB
2) Tanda Vital :
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4) Pemeriksaan integumen
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5) Dada dan thorax
a. Paru – Paru
Inspeksi : ....................................................................................................
Palpasi : ......................................................................................................
Perkusi : ......................................................................................................
Auskultasi : .................................................................................................
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b. Jantung
Inspeksi : .....................................................................................................
Palpasi : ......................................................................................................
Perkusi : ......................................................................................................
Auskultasi : ..................................................................................................
6) Payudara
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7) Abdomen
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8) Genetalia
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9) Ekstrimitas
a. Atas
Kekuatan Otot : ..........................................................................................
ROM : .........................................................................................................
Akral : .........................................................................................................
b. Bawah
Kekuatan Otot : ...........................................................................................
ROM : .........................................................................................................
Varises : .......................................................................................................
Akral : .........................................................................................................
j. Pemeriksaan Neurologis
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k. Pemeriksaan Penujang
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l. Terapi/Pengobatan/Penatalaksanaan
Cairan IV : .........................................................................................................
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Surakarta, ..............................
Mahasiswa
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