: ............................................................................
Tanggal Pengkajian
: ............................................................................
Jam pengkajian
: ............................................................................
A. Biodata :
1. Pasien
Nama
Umur
Agama
Pendidikan
Pekerjaan
Status Pernikahan
Alamat
Tanggal masuk RS
Jam masuk RS
Diagnosa Medis
2. Pasien
Nama
Umur
Agama
Pendidikan
Pekerjaan
Status Pernikahan
Alamat
C. Keluhan utama
D. Riwayat Kesehatan
a.
b.
c.
E. Genogram
F.
Primary Survey
1. Air Way
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2. Breathing
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3. Circulation
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4. Disability
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5. Exposure/Environtment
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G. Secondary Survey
1. Kepala :
a. Kulit
: ................................................................................
b. Rambut
: ................................................................................
c. Muka
: ................................................................................
d. Mata
1) Konjungtiva
: ....................................................................
2) Sclera
: ....................................................................
3) Bentuk Pupil
: ....................................................................
4) Ukuran Pupil
: ....................................................................
5) Reflek Pupil
: ....................................................................
6) Palpebra
: ....................................................................
7) Lensa
: ....................................................................
8) Visus
: ....................................................................
2. Hidung
: ................................................................................
3. Mulut
: ................................................................................
4. Gigi
: ................................................................................
5. Bibir
: ................................................................................
6. Telinga
: ................................................................................
7. Leher
: ................................................................................
8. Tenggorokan : .............................................................................
9. Dada
: .............................................................................
a. Pulmo
Inspeksi : .............................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
Program Pendidikan Profesi Ners FIKES7Universitas Respati Yogyakarta
(Unriyo)
Auskultasi : ........................................................................
b. Cor
Inspeksi : .............................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
.............................................................................
.............................................................................
.............................................................................
Auskultasi : ........................................................................
10. Abdomen
Inspeksi : .............................................................................
Auskultasi : ........................................................................
Palpasi : .............................................................................
Perkusi : .............................................................................
11.Punggung
Inspeksi : .............................................................................
Palpasi : .............................................................................
12. Genetalia
1) Pria
: .............................................................................
.............................................................................
2) Perempuan : .........................................................................
.............................................................................
Program Pendidikan Profesi Ners FIKES8Universitas Respati Yogyakarta
(Unriyo)
Atas
: ....................................................................
.........
.............................................................................
.............................................................................
2) Bawah : .............................................................................
.............................................................................
.............................................................................
H. Basic Promoting physiology of Health
1.
Sebelum Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
b.
Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
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.....................................................................................
2.
: .....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
3.
: .....................................................................................
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.....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
Data Subyektif
Provocatif
: ...................................................................
...................................................................
...................................................................
...................................................................
Paliatif
: ...................................................................
...................................................................
...................................................................
...................................................................
Quality
: ...................................................................
...................................................................
...................................................................
...................................................................
Severity
: ...................................................................
...................................................................
...................................................................
...................................................................
Time
: ...................................................................
...................................................................
...................................................................
...................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
4.
Nutrisi
a. Sebelum Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
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5.
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
6.
Oksigenasi
a. Sebelum Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
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7.
Eliminasi Fekal/Bowel
a. Sebelum Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
8.
Eliminasi urin
a. Sebelum Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
9.
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
b. Selama Sakit
DS
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
DO
: .....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
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I.
b.
c.
d.
e.
2. Sosial :
a.
b.
c.
Cara mengatasinya:
d.
3. Budaya :
a.
b.
4. Spiritual :
a.
b.
c.
J.
Pemeriksaan Penunjang
(Hasil pemeriksaan laboratorium,radiology, EKG,EEG dll)
Jenis Pemeriksaan
Hari/Tanggal
NO
:
:
JENIS PEMERIKSAAN
NILAI NORMAL
HASIL
INTERPRETASI
K. Terapi Medis
No
Nama Terapi
Dosis
Fungsi
PRAKTIK
KLINIK
KEBUTUHAN
DASAR MANUSIA
PROGRAM
PENDIDIKAN
PROFESI
NERS
PROGRAM STUDI S-1 ILMU KEPERAWATAN
UNIVERSITAS RESPATI YOGYAKARTA
UNIVERSITAS RESPATI YOGYAKARTA
ANALISA DATA
Nama klien
Umur
Ruang Rawat :
TGL/JAM
DATA FOKUS
Alamat
ETIOLOGI
:...
:
PROBLEM
:
:
:
No Diagnosa Keperawatan
Nama klien
Umur
Ruang
RENCANA TINDAKAN
Intervensi
No. Register
Di agnosa Medis
Al amat
Rasional isasi
: ..
:..
: ..
Nama/TTD
No.Dx
Tanggal
Nama klien
Umur
Ruang
Jam
:
:
:
Implement asi
No. Register
Di agnosa Medis
Al amat
Evaluasi
: ..
:..
: ..
Nama/TTD