FORMAT PENGKAJIAN

APLIKASI TEORI MODEL SELF CARE OREM
STIKES HANG TUAH SURABAYA

A. PENGKAJIAN
1. Universal Self Care
a. Kebutuhan oksigen
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b. Kebutuhan Cairan
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c. Kebutuhan Nutrisi
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d. Kebutuhan Eliminasi
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e. Interaksi Sosial
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f. Istirahat dan Tidur
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g. Konsep Diri
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2. Development Self Care
a. Identitas Anggota kelompok
1)
Usia : .......... tahun
2)
Jenis kelamin :
L/P
3)
Pendidikan
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4)
Agama : .................................................................................................................
5)
Pekerjaaan
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6)
Suku : .................................................................................................................
b. Penyakit Keturunan
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c. Persepsi terhadap penyakitnya
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d. Pengetahuan Terhadap Penyakit
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3. Health Deviation
a. Tindakan preventif yang dilakukan untuk mengatasi masalah
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b. Halangan untuk melakukan tindakan preventif
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B. DIAGNOSA KEPERAWATAN
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No dx

Penuh/wholly

RENCANA KEPERAWATAN
Sebagian/partial

Supportif Edukatif

IMPLEMENTASI DAN EVALUASI
No. Dx

Implementasi

Evaluasi

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