FORMAT PENGKAJIAN UJIAN AKHIR SIKLUS KEPERAWATAN ANAK

PROGRAM STUDI ILMU KEPERAWATAN

STIKES SYEDZA SAINTIKA PADANG

Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal & jam pengkajian :
I. PENGKAJIAN
1. Identitas pasien
a. Nama klien : ..............................................................
b. No. Rekam Medis : ..............................................................
c. Tanggal lahir/ Umur : ..............................................................
d. Jenis kelamin : ..............................................................
e. Nama Ibu : ..............................................................
f. Diagnosa Medis : ..............................................................
g. Hari rawatan ke : ………………………………………….

2. Alasan Masuk RS
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3. Riwayat Kesehatan Dahulu

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4. Riwayat Kesehatan Keluarga

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5. Riwayat Kesehatan Sekarang
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6. Pengkajian Terfokus
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7. WOC
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ANALISA DATA

Inisial Pasien : ................................. Umur : .................................

Tanggal : ................................. Diagnosa Medis: .................................
Nomor Register: ................................. Ruang / Kamar : .................................

NO DATA FOKUS MASALAH

PATHWAY
(SUBJEKTIF DAN OBJEKTIF) KEPERAWATAN
NO DATA FOKUS MASALAH
PATHWAY
(SUBJEKTIF DAN OBJEKTIF) KEPERAWATAN
 I. DIAGNOSA KEPERAWATAN

NO DAFTAR DIAGNOSA KEPERAWATAN

(BERDASARKAN PRIORITAS MASALAH)
 II. RENCANA KEPERAWATAN

Inisial Pasien/ Umur : ................................. Nomor Register : .................................

Hari rawatan ke : ................................. Tanggal/ Shift : .................................
Diagnosa Medis : ................................. Ruang / Kamar : .................................

No MASALAH OUTCOME DAN INTERVENSI AKTIVITAS

KEPERAWATAN INDIKATOR (NOC) NIC
No MASALAH OUTCOME DAN INTERVENSI AKTIVITAS
KEPERAWATAN INDIKATOR (NOC) NIC
 III. IMPLEMENTASI
CATATAN PERKEMBANGAN ASUHAN KEPERAWATAN ANAK

Inisial Pasien : ............................... Tanggal : ……………………………….

Ruang / Kamar : ............................... Hari rawatan ke : …………………………………

DIAGNOSA PUKUL
IMPLEMENTASI KEPERAWATAN EVALUASI
KEPERAWATAN

DIAGNOSA PUKUL IMPLEMENTASI KEPERAWATAN EVALUASI

KEPERAWATAN