641 lines
18 KiB
PHP
641 lines
18 KiB
PHP
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
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<html xmlns="http://www.w3.org/1999/xhtml">
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<head>
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<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
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<title>Untitled Document</title>
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</head>
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<body>
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<form name="pengkajian_dewasa" id="pengkajian_dewasa" action="ranap/save_pengkajian_dewasa.php" method="post">
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<table width="95%" border="0" cellpadding="0" cellspacing="0" class="tb">
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<tr>
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<td colspan="6"><strong>PENGKAJIAN PASIEN RAWAT INAP</strong></td>
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</tr>
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<tr>
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<td colspan="6"><hr /></td>
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</tr>
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<tr>
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<td width="28%">Yang Mengantar </td>
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<td width="28%"><input type="text" size="50" class="text" name="pengantar" /></td>
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<td width="3%"> </td>
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<td width="39%"> </td>
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<td width="1%"> </td>
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<td width="1%"> </td>
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</tr>
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<tr>
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<td>Hubungan dengan Pasien</td>
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<td><input type="text" size="20" class="text" name="hubungan" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Tekanan Darah </td>
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<td><input type="text" size="10" class="text" name="tekanan_darah" />
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mmHg</td>
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<td>E</td>
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<td><input type="text" size="10" class="text" name="e" /></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td> Suhu </td>
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<td><input type="text" size="10" class="text" name="suhu" />
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oC</td>
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<td>V</td>
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<td><input type="text" size="10" class="text" name="v" /></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Nadi</td>
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<td><input type="text" size="10" class="text" name="nadi" />
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x/m</td>
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<td>m</td>
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<td><input type="text" size="10" class="text" name="m" /></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>RR</td>
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<td><input type="text" size="10" class="text" name="rr" />
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x/m</td>
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<td>GCS</td>
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<td><input type="text" size="10" class="text" name="gsc" /></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>TB </td>
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<td><input type="text" size="10" class="text" name="tb" />
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cm</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td> BB </td>
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<td><input type="text" size="10" class="text" name="bb" />
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kg</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td> Nilai </td>
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<td><input type="text" size="10" class="text" name="nilai" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Kesadaran: </td>
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<td><input type="text" size="30" class="text" name="kesadaran" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td> Cara Masuk : </td>
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<td>
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<input type="radio" name="datang_dari" value="1" /> Berjalan ?
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<input type="radio" name="datang_dari" value="1" /> Kursi Roda ?
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<input type="radio" name="datang_dari" value="1" /> Brankar
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</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Datang dari : </td>
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<td>
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<input type="radio" name="datang_dari" value="1" /> Admission
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<input type="radio" name="datang_dari" value="2" /> IGD
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<input type="radio" name="datang_dari" value="3" /> Poli<span id="poli_coices"></span></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td colspan="6"><strong>RIWAYAT KESEHATAN</strong></td>
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</tr>
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<tr>
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<td colspan="6"><hr /></td>
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</tr>
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<tr>
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<td>Diagnosa Medis Saat Masuk </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Alasan Masuk :</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Riwayat Medis </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Pernah Masuk RS </td>
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<td><input type="radio" name="ya" id="ya" value="1" />
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Ya <span id="ya"></span>
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<input type="radio" name="tidak" id="tidak" value="2" /> Tidak
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</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Medical </td>
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<td><input type="text" size="20" name="medical" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Bedah</td>
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<td><input type="text" size="20" name="bedah" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td valign="top">- Alergi : </td>
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<td colspan="3"><input name="alergi" type="checkbox" value="1"/>
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Ashma
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<input name="alergi" type="checkbox" value="2"/> Hay Fever/bersin-bersin
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<input name="alergi" type="checkbox" value="3"/> Eksim
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<input name="alergi" type="checkbox" value="4"/> Gatal-gatal <br />
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<input name="alergi" type="checkbox" value="5"/> Makanan <input type="text" size="20" name="ket1" class="text" /><br />
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<input name="alergi" type="checkbox" value="6"/> Obat <input type="text" size="20" name="ket2" class="text" /><br />
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<input name="alergi" type="checkbox" value="7"/> Lainnya <input type="text" size="20" name="ket3" class="text" /><br />
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</td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Riwayat Injuri/Kecelakaan/Kasus Ortopedi </td>
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<td><input type="text" size="50" name="riwayat" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Kebiasaan :</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Makan </td>
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<td><input type="text" size="30" name="makanan" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Perilaku </td>
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<td><input type="text" size="30" name="prilaku" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Hygiene </td>
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<td><input type="text" size="30" name="hygiene" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Aktivitas </td>
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<td><input type="text" size="30" name="aktivitas" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- Tidur</td>
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<td><input type="text" size="30" name="tidur" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Eliminasi :</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- BAB </td>
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<td><input type="text" size="30" name="bab" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>- BAK </td>
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<td><input type="text" size="30" name="bak" class="text" /></td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td colspan="6">
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<strong>PENGOBATAN</strong>
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<table width="90%" align="left" border="0" class="tb">
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<tr>
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<td width="21%">Nama Obat</td>
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<td width="79%"><input type="text" size="50" name="nama_obat2" class="text" /></td>
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</tr>
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<tr>
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<td>Dosis</td>
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<td><input type="text" size="50" name="dosis" class="text" /></td>
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</tr>
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<tr>
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<td>Frekuensi</td>
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<td><input type="text" size="50" name="frekuensi" class="text" /></td>
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</tr>
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<tr>
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<td>Lama Pemberian</td>
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<td><input type="text" size="50" name="lama_pemberian" class="text" /></td>
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</tr>
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<tr>
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<td>Dosis Terakhir yang Diberikan</td>
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<td><input type="text" size="50" name="dosis_terakhir" class="text" /></td>
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</tr>
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<tr>
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<td> </td>
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<td><input type="submit" class="text" name="tambah" value="tambah"/></td>
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</tr>
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</table>
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</td>
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</tr>
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<tr>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td colspan="6"><strong>COPING</strong></td>
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</tr>
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<tr>
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<td>Riwayat Sosial :</td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Respon : </td>
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<td colspan="3">Gangguan Kooperatif Lainnya
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<input name="gangguan" type="text"/></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Komunikasi : </td>
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<td colspan="3">Gangguan Bingung Lainnya
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<input name="komunikasi" type="text"/></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Dampak Masuk RS :</td>
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<td colspan="3">(sedih, cemas, menangis, dll)
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<input name="dampak" type="text"/></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Status Pernikahan : </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Tempat Tinggal : </td>
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<td colspan="3">
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<input type="radio" name="ttinggal" value="1" /> Sendiri
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<input type="radio" name="ttinggal" value="2" /> Dengan
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<input type="radio" name="ttinggal" value="3" /> Keluarga
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<input type="radio" name="ttinggal" value="4" /> Menumpang
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<input type="radio" name="ttinggal" value="5" /> Penampungan
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</td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Kebutuhan Khusus : </td>
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<td colspan="3">
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<input type="radio" name="kebutuhan_khusus" value="1" /> Kursi Roda
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<input type="radio" name="kebutuhan_khusus" value="2" /> Kruk
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<input type="radio" name="kebutuhan_khusus" value="3" /> Lainnya
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<input name="kebutuhan_khusus_lainnya" type="text"/></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Riwayat Keluarga : </td>
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<td colspan="3"><p>
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<input type="radio" name="riwayat_keluarga" value="1" /> DM
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<input type="radio" name="riwayat_keluarga" value="2" /> Kanker
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<input type="radio" name="riwayat_keluarga" value="3" /> Hipertensi
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<input type="radio" name="riwayat_keluarga" value="4" /> Jantung
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<input type="radio" name="riwayat_keluarga" value="5" /> TBC
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<input type="radio" name="riwayat_keluarga" value="6" /> Anemia
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<input type="radio" name="riwayat_keluarga" value="7" /> Lainnya
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<input name="riwayat_lainnya" type="text" />
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</p></td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Konsumsi Alkohol/Narkoba :</td>
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<td colspan="3">
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<input type="radio" name="alkohol" value="1" /> Tidak
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<input type="radio" name="alkohol" value="1" /> Ya,
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Jenis <input name="alkohol_jenis" type="text" />
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Sejak <input name="alkohol_sejak" type="text" />
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</td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td>Merokok :</td>
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<td colspan="5"><input type="radio" name="merokok" value="1" /> Tidak <input type="radio" name="merokok" value="1" /> Ya, Jumlah per hari <input name="jml_perhari" type="text" /> Sejak
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<input name="rokok_sejak" type="text" />
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Berhenti sejak
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<input name="berhenti_sejak" type="text" /></td>
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</tr>
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<tr>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td colspan="6"><strong>PENGKAJIAN RESIKO JATUH</strong></td>
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</tr>
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<tr>
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<td colspan="6"><hr /></td>
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</tr>
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<tr>
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<td colspan="6">Tidak Beresiko ? Umur: =65 Th atau = 3 Th ? Gizi Buruk ? Inkontinensia
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? Gangguan Neuro/Ortopedi ? Peny. Kardiovaskuler ? Pengaruh Analgetik/Hipnotik
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? Kelemahan ? Bingung ? Gangguan Penglihatan ? Keterbatasan Mobilisasi
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? Riwayat Pingsan/Jatuh ? Lainnya
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<input name="resiko" size="30" type="text" class="text"/></td>
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</tr>
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<tr style="">
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td colspan="6"><strong>PENGKAJIAN SISTEM TUBUH</strong></td>
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</tr>
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<tr>
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<td><p>Respiratori</p></td>
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<td colspan="5">
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<input type="radio" name="respiratori" value="1" /> Normal
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<input type="radio" name="respiratori" value="2" /> Nyeri
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<input type="radio" name="respiratori" value="3" /> Batuk
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<input type="radio" name="respiratori" value="4" /> Dyspnoe
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<input type="radio" name="respiratori" value="5" /> Sputum
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||
<input type="radio" name="respiratori" value="6" /> Penjelasan
|
||
<input name="respiratori_penjelasan" size="30" class="text" type="text"/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td valign="top">Sirkulasi</td>
|
||
<td colspan="5">
|
||
<input type="radio" name="sirkulasi" value="1" /> Normal
|
||
<input type="radio" name="sirkulasi" value="2" /> Edema
|
||
<input type="radio" name="sirkulasi" value="3" /> Perdarahan
|
||
<input type="radio" name="sirkulasi" value="4" /> Syncope
|
||
<input type="radio" name="sirkulasi" value="5" /> Palpitasi<br />
|
||
<input type="radio" name="sirkulasi" value="6" /> Murmur
|
||
<input type="radio" name="sirkulasi" value="7" /> Pacemaker
|
||
<input type="radio" name="sirkulasi" value="8" /> Penjelasan
|
||
<input name="sirkulasi_penjelasan2" size="30" class="text" type="text"/>
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td>Nutrisi</td>
|
||
<td><input type="text" name="nutrisi" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Eliminasi</td>
|
||
<td><input type="text" name="eliminasi" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Bowel</td>
|
||
<td><input type="text" name="bowel" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Bladder</td>
|
||
<td><input type="text" name="bladder" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Integumen</td>
|
||
<td><input type="text" name="integumen" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Reproduksi</td>
|
||
<td><input type="text" name="reproduksi" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Aktifitas seksual</td>
|
||
<td><input type="text" name="aktifitas_seksual" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Jumlah Anak</td>
|
||
<td><input type="text" name="jumlah_anak" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Kontrasepsi</td>
|
||
<td><input type="text" name="kontrasepsi" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td valign="top"><p><strong>Aktifitas</strong></p></td>
|
||
<td colspan="5">
|
||
<input type="radio" name="sirkulasi" value="1" /> Normal
|
||
<input type="radio" name="sirkulasi" value="2" /> Lemah
|
||
<input type="radio" name="sirkulasi" value="3" /> Kram
|
||
<input type="radio" name="sirkulasi" value="4" /> Nyeri Ekstrimitas
|
||
<input type="radio" name="sirkulasi" value="5" /> Kontraktur<br />
|
||
<input type="radio" name="sirkulasi" value="6" /> Nyeri Otot
|
||
<input type="radio" name="sirkulasi" value="7" /> Deformitas
|
||
<input type="radio" name="sirkulasi" value="8" /> Arthritis
|
||
<input type="radio" name="sirkulasi" value="9" /> Amputasi<br />
|
||
<input type="radio" name="sirkulasi" value="10" /> Penjelasan
|
||
<input type="text" name="aktifitas_penjelasan" class="text" size="30" />
|
||
</td>
|
||
</tr>
|
||
<tr>
|
||
<td valign="top"><strong>Rasa Nyaman</strong></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Jelaskan nyeri yang dirasakan</td>
|
||
<td><input type="text" name="penjelasan_yg_dirasakan" class="text" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td>Yang dilakukan untuk mengurangi/menghilangkan nyeri </td>
|
||
<td valign="top"><input type="text" class="text" name="tindakan" size="30" /></td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
<tr>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
<td> </td>
|
||
</tr>
|
||
</table>
|
||
|
||
</form>
|
||
</body>
|
||
</html> |