A.

PENGKAJIAN
Tanggal

Jam

1. Identitas
Nama

Umur

Jenis kelamin

Pendidikan

Pekerjaan

Alamat

No. Reg

Diagnosa medis

2. Riwayat kesehatan
a.

Keluhan Utama

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b.

Riwayat Penyakit Sekarang

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c.

Riwayat Penyakit Dahulu

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d.

Riwayat Penyakit Keluarga

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3. Pola kesehatan fungsional

a. Pola Kesehatan Dan Pola Manajemen Kesehatan
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b. Pola Nutrisi Metabolik
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c. Pola Eliminasi
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d. Pola Aktivitas-Latihan
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Kemampuan
0
1
2
3
4
Perawatan Diri
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Ambulasi/ROM
Keterangan: 0 : mandiri, 1: alat bantu, 2 : dibantu orang lain, 3 : dibantu orang
lain dan alat, 4 : tergantung total.
e. Pola Istirahat-Tidur
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f. Pola Persepsi Kognitif

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g. Pola Konsep Diri
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h. Pola Peran dan hubungan
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i. Pola Reproduksi dan Seksual
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j. Pola Pertahanan diri/koping
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k. Pola Keyakinan dan Nilai
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4. Pemeriksaan fisik
Kesadaran
Keadaan Umum/Kesadaran :

, GCS =

Tanda Vital
Tanda Vital : TD=

N:

BB:

TB:

S:

Head To Toe
1.

Kepala/leher
Kepala

Leher

Mata

Hidung

Telinga

Mulut dan gigi

2.

Dada (jantung/paru)
a. Paru
Inspeksi

Palpasi

Perkusi

Auskultasi

b. Jantung
Inspeksi
Palpasi
Perkusi
Auskultasi

:
:
:
:

3.

Payudara

4.

Abdomen
a.

Inspeksi

b.

Auskultasi

c.

Perkusi

d. Palpasi

5.

Genitalia

6.

Ekstremitas

RR:

Atas

Bawah

Varises

Kekuatan otot

5. Pemeriksaan Penunjang Laboratorium

Pemeriksaan

6. Terapi

7. Pemeriksaan lain

B. ANALISA DATA

Hasil

Satuan

Nilai Normal

Tanggal
1.

Data

Problem

Etiologi

D. DIAGNOSA KEPERAWATAN

E. RENCANA KEPERAWATAN
Tgl/jam

No
DP

Tujuan

Intervensi

Rasional

F. IMPLEMENTASI

TGL/JAM

NO DP

IMPLEMENTASI

RESPON PASIEN

PARAF

G. EVALUASI
TGL/JAM

NO DP

EVALUASI

PARAF