I. IDENTITAS
1. Nama
2. Umur
3. Jenis kelamin
4. Status
5. Agama
6. Suku/bangsa
7. Bahasa
8. Pendidikan
9. Pekerjaan
10. Alamat dan no. telp
11. Penanggung jawab
:
:
:
:
:
:
:
:
:
:
:
Tgl/jam MRS
No. RM
Ruangan/kelas
No.kamar
:
:
:
:
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SMRS
2
3
MRS
2
3
Mandi
Berpakaian/berdandan
Eliminasi/toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah
Skor
0 = mandiri
1 = alat bantu
2 = dibantu orang lain
:
:
:
:
:
Di rumah sakit
Frekuensi : ..................................
Jenis
: ..................................
Porsi
: ..................................
Diit khusus : ..................................
( ) bertambah
( ) muntah, .............. cc
) ya
) ya
) ya
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5. Pola Eliminasi
a. Buang air besar
Di rumah
Frekuensi : ..................................
Konsistensi : ..................................
Warna
: ..................................
Masalah di RS : ( ) konstipasi ( ) diare
Kolostomi
: ( ) tidak ( ) ya
( ) berkurang
( ) stomatitis
Di rumah sakit
Frekuensi : ..................................
Jenis
: ..................................
Jumlah
: ..................................
Di rumah sakit
Frekuensi : ..................................
Konsistensi : ..................................
Warna
: ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
( ) inkontinen
:
:
:
:
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T : .................................................................................................................................
7. Pola Konsep Diri
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8. Pola Koping
Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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Kehilangan perubahan yang terjadi sebelumnya
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Kemampuan adaptasi
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9. Pola Seksual Reproduksi
Menstruasi terakhir : .....................................................................................................................
Masalah menstruasi : .....................................................................................................................
Pap smear terakhir : .....................................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan
: ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit : ...............................................................
10. Pola Peran Hubungan
Pekerjaan
Kualitas bekerja
Hubungan dengan orang lain
Sistem pendukung
:
:
:
:
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( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya, .................................................................................
Masalah keluarga mengenai perawatan di RS : .............................................................................
:
:
:
:
................................................................................................
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( ) tidak ( ) ya, ................................................................
( ) tidak ( ) ya
pulsasi : ......................
V. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Photo
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3. Lain-lain
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VI. TERAPI
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Surabaya, .....................
Mahasiswa
(...............................)
ANALISA DATA
Nama klien
Umur
No.
: ..............................................
: ..............................................
Data (Symptom)
Ruangan/kamar : ..............................................
No. RM
: ..............................................
Penyebab (Etiologi)
Masalah (Problem)
PRIORITAS MASALAH
Nama klien
Umur
No.
: ..............................................
: ..............................................
Masalah Keperawatan
Ruangan/kamar : ..............................................
No. RM
: ..............................................
Tanggal
Ditemukan
Teratasi
Paraf
(Nama Perawat
RENCANA KEPERAWATAN
No.
Diagnosa Keperawatan
Intervensi
Rasional
Waktu
Tgl/jam
Tindakan
TT
Waktu
Tgl/jam
Catatan Perkembangan
(SOAP)
TT