SOEPRAOEN
POLITEKNIK KESEHATAN
PROGRAM STUDI KEPERAWATAN
Nama mahasiswa :
NIM :
PENGKAJIAN
Dilaksanakan tgl : …………………………………………
Ruang : ………………………………………….
No kamar/ TT : ………………………………………….
1. Biodata
Nama : …………………………………………………………..
Umur : ……………………………………………………………
Agama : …………………………………………………………….
Alamat : …………………………………………………………….
Pendidikan : …………………………………………………………….
Pekerjaan : …………………………………………………………….
No. reg :
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Nama : ……………………………………………………………
Pekerjaan : ……………………………………………………………
Alamat : ……………………………………………………………
Hubungan Keluarga : ……………………………………………………………
2. Keluhan
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b. Keluhan saat pengkajian :
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2. Minum
3. Eliminasi BA.B
4. Eliminasi BAK
5. Istirahat/tidur
6. Aktifitas /latihan/
Olahraga
Lain-lain
Pemeriksaan fisik :
a. Keadaan /penampilan/Kesan Umum pasien :
b. Tanda-tanda vital :
Kepala :
Rambut :
Wajah :
Mata :
Hidung :
Telinga:
Mulut :
Faring :
Leher :
e. Pemeriksaan Thorak/Dada :
Paru : (Inspeksi,Perkusi,Palpasi,Auskultasi)
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Jantung : (Inspeksi, Perkusi, Palpasi, Auskultasi)
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f. Pemeriksaan Abdomen(Inspeksi, Perkusi, Palpasi, Auskultasi)
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l. Penatalaksanan / Therapi :
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Malang, ……………….
Perawat
ANALISA DATA
NAMA PASIEN :
UMUR :
NO. REGISTER :
NAMA PASIEN :
UMUR :
NO. REGISTER :
NAMA PASIEN :
UMUR :
NO. REGISTER :
NO DIAGNOSA KEPERAWATAN TTD
DAFTAR DIAGNOSA KEPERAWATAN
NAMA PASIEN :
UMUR :
NO. REGISTER :
NO DIAGNOSA KEPERAWATAN TTD
RENCANA ASUHAN KEPERAWATAN
NAMA PASIEN:
UMUR :
NO. REG :
NO. DIAGNOSA TUJUAN INTERVENSI RASIONAL TTD
KEPERAWATAN
RENCANA ASUHAN KEPERAWATAN
NAMA PASIEN:
UMUR :
NO. REG :
NO. DIAGNOSA TUJUAN INTERVENSI RASIONAL TTD
KEPERAWATAN
RENCANA ASUHAN KEPERAWATAN
NAMA PASIEN:
UMUR :
NO. REG :
NO. DIAGNOSA TUJUAN INTERVENSI RASIONAL TTD
KEPERAWATAN
CATATAN KEPERAWATAN
NAMA PASIEN:
UMUR :
NO. REGISTER :
NAMA PASIEN:
UMUR :
NO. REGISTER :
NAMA PASIEN:
UMUR :
NO. REGISTER :
NAMA PASIEN:
UMUR :
DX. MEDIS :
NAMA PASIEN:
UMUR :
DX. MEDIS :
NO. TGL/ CATATAN PERKEMBANGAN TTD.
DX. JAM
KEP
NAMA PASIEN:
UMUR :
DX. MEDIS :
NO. TGL/ CATATAN PERKEMBANGAN TTD.
DX. JAM
KEP