Riwayat Rekreasi

Hobi/minat

:..

Keanggotaan organisasi

:..

Liburan perjalanan

:..

Sistem Pendukung
Perawat/Bidan/Dokter/Fisioterapi

:..

Jarak dari rumah

:..

Rumah sakit

:..

Klinik

:..

Pelayanan Kesehatan di rumah

:..............

Perwatan sehari-hari yang dilakukan keluarga

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
Lain-lain

Deskripsi/kekhususan
Kebiasaan ritual

:......................................................................................................................

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
Hal lainnya

:......................................................................................................................

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Status Kesehatan
Status kesehatan umum selama setahun yang lalu

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............................................................................................................................................................
............................................................................................................................................................
Status kesehatan selamam 5 tahun yang lalau

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Aktifitas Hidup sehari-hari

No
A

INDEKS KATZ
Criteria
Kemandirian dalam hal makan, kontinen, berpindah, ke kemar kwcil, berpakaian, dan

B
C

mandi
Kemandirian dalam semua aktifita hidup sehari-hari, kecuali satu dari fungsi tersebut
Kemandirian dalam semua aktifita hidup sehari-hari, kecuali mandi dan satu dari fungsi

tersebut
Kemandirian dalam semua aktifita hidup sehari-hari, kecuali mandi, berpakaian dan satu

dari fungsi tersebut

Kemandirian dalam semua aktifita hidup sehari-hari, kecuali mandi, berpakaian, ke

kamar kecil dan satu dari fungsi tersebut

Kemandirian dalam semua aktifita hidup sehari-hari, kecuali mandi, berpakaian,

berpindah, dan satu dari fungsi tersebut

G
Ketergantungan pada enam fungsi tersebut
Lain- Ketergantungan pada sedikitnya dan fungsi, tetapi tidag dapat di klasifikasikan sebagai
lain

C, D, E, F. G

Oksigenisasi :
............................................................................................................................................................
............................................................................................................................................................

Cairan elektrolit

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Nutrisi :

............................................................................................................................................................
............................................................................................................................................................
Eliminasi

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Aktifitas

............................................................................................................................................................
............................................................................................................................................................
Istirtahat dan tidur

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Personal Hygiene

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Seksual

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Rekreasi

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Psikologis

Persepsi klien :..................................................................................................................................

...................................................................................................................................
Konsep diri

:..................................................................................................................................
...................................................................................................................................

Emosi

:..................................................................................................................................
...................................................................................................................................

Adaptasi

:..................................................................................................................................
...................................................................................................................................

Mekanisme Pertahanan diri

............................................................................................................................................................
............................................................................................................................................................
Tujuan system
Keadaan umum

:......................................................................................................................
.......................................................................................................................

Tingkat Kesadaran : Composmentis/Apatis/Somnolen/Supor/Koma

Glasgow Coma Scale (GCS)

Verbal

:..................................................................................................................................

Psikomotor

:..................................................................................................................................

Mata

:..................................................................................................................................

Tanda-tanda Vital

Nadi

:......................................

Suhu

:..............................................

Tekanan Darah

:......................................

RR

:..............................................

1. Kepala
................................................................................................................................................
................................................................................................................................................
2. Mata, Telinga dan Hidung
................................................................................................................................................
................................................................................................................................................
3. Leher
................................................................................................................................................
................................................................................................................................................
4. Dada dan Punggung
................................................................................................................................................
................................................................................................................................................
5. Abdomen dan Pinggan
................................................................................................................................................
................................................................................................................................................
6. Ekstremitas Atas dan Bawah
................................................................................................................................................
................................................................................................................................................
7. System Imun
................................................................................................................................................
................................................................................................................................................
8. Genitalia
................................................................................................................................................
................................................................................................................................................
9. Sistem Reproduksi

10. Sistem persarafan

....
11. Sistem Pengecapan

12. Sistem Penciuman

13. Respon Takstil

Status kognitif/Afektif dan Sosial

1. Short Portable Mental Status Questionare (SPMSQ)

2. Mini Mental State Exam (MMSE)

3. Inventaris Depresi Beck

4. APGAR Keluarga

Data Penunjang
1. Laboratorium
................................................................................................................................................
................................................................................................................................................
2. Radiologi

3. EKG

4. USG

5. CT Scan

....
6. Obat-obatan

Analisa Data
No

Data
Tanda dan Gejala

Interprestasi

Masalah (Problem)

(Etiologi)

Prioritas Masalah
1.
2. ...
3. ...
4.
Proses Keperawatan
Diagnosis Keperawata I
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............................................................................................................................................................
Tujuan

Kriteria Hasil :

Intervensi
Intervensi Keperawatan

:..

Observasi Monitoring

:..........................................................................................................

Pendidikan Kesehatan

:..........................................................................................................

Kolaborasi

:..

Intervensi

Rasional

Diagnosis Keperawatan 2
............................................................................................................................................................
............................................................................................................................................................
Tujuan

Kriteria Hasil :

Intervensi

Intervensi Keperawatan

:..

Observasi Monitoring

:..

Pendidikan Kesehatan

:..

Kolaborasi

:..

Intervensi

Rasional

Diagnosis Keperawatam 3

Tujuan :
............................................................................................................................................................
............................................................................................................................................................
Kriteria Hasil :

Intervensi
Intervensi Keperawatan

:..

Observasi Monitoring

:..

Pendidikan Kesehatan

:..........................................................................................................

Kolaborasi

:..

Intervensi

Rasional

Catatan Perkembangan Keperawatan

No

Hari,Tanggal,jam

Diagnosa

Perkembangan

Keperawatan

Keperawatan

Tanda Tangan