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- Riwayat penyakit dahulu Apakah klien pernah mengalami penyakit ini sebelumnya,apakah klien menderita penyakit DM - Riwayat penyakit keluarga Biasanya keluarga tidak pernah mengalami penyakit seperti ini, karena ISK bukan penyakit keturunan. 3.2 Pemeriksaan fisik A.Pemeriksaan Head To Toe 1. Keadaan umum : klien nampak pucat, keasadaran composmentis. 2. Tanda vital : (Tanda-tanda vital seluruhnya mengalami penigkatan yang menandakan proses penyakit infeksius akut). TD : > 120/70 (Meningkat) Nadi : > 100x/menit (Meningkat) Suhu : > 37,5 o C (Meningkat) RR : > 20x/menit (Meningkat) 3. Kepala : mesosepal, rambut hitam, tipis, bersih 4. Mata : anemis (-), sclera ikterik (-), pupil terhadap cahaya (+) 5. Hidung : cuping hidung (-), secret (-), epistaksis (-), tidak terpasan NGT 6. Telinga : serumen (-), bentuk simetris 7. Leher : tidak ada kelainan 8. Dada : bentuk normal, pengembangan dada simetris, (-) retraksi dinding dada 9. Jantung : Inspeksi : tidak ada pembesaran 13

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Riwayat penyakit dahulu

Apakah klien pernah mengalami penyakit ini sebelumnya,apakah klien menderita penyakit DM

Riwayat penyakit keluarga

Biasanya keluarga tidak pernah mengalami penyakit seperti ini, karena ISK bukan penyakit keturunan.3.2 Pemeriksaan fisik

A. Pemeriksaan Head To Toe

1. Keadaan umum : klien nampak pucat, keasadaran composmentis.

2. Tanda vital : (Tanda-tanda vital seluruhnya mengalami penigkatan yang menandakan proses penyakit infeksius akut). TD : > 120/70 (Meningkat) Nadi : > 100x/menit (Meningkat) Suhu : > 37,5 oC (Meningkat) RR : > 20x/menit (Meningkat)3. Kepala: mesosepal, rambut hitam, tipis, bersih4. Mata: anemis (-), sclera ikterik (-), pupil terhadap cahaya (+)

5. Hidung

: cuping hidung (-), secret (-), epistaksis (-), tidak terpasan NGT

6. Telinga: serumen (-), bentuk simetris

7. Leher: tidak ada kelainan8. Dada

:bentuk normal, pengembangan dada simetris, (-) retraksi dinding dada9. Jantung :

Inspeksi: tidak ada pembesaran

Palpasi: tidak teraba adanya pembesaran

Perkusi: bunyi jantung pekak

Auskultasi: BJ1 dan BJ2 tunggal

10. Paru-paru :

Inspeksi: pengembangan paru kanan kiri simetris

Palpasi: biasanya tidak ada nyeri tekan 13


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