BAB II

TINJAUAN KASUS

A. IDENTITAS KLIEN
Nama :
Umur :
Jenis kelamin :
Alamat :
Status :
Agama :
Suku :
Pendidikan :
Pekerjaan :
Tanggal masuk RS :
Tanggal pengkajian :
DX Medis :
B. IDENTITAS PENANGGUNG JAWAB
Nama :
Umur :
Jenis kelamin :
Alamat :
Pendidikan :
Pekerjaan :
C. PENGKAJIAN
1. Keluhan Utama
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2. Riwayat Kesehatan Sekarang

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3. Riwayat Kesehatan Dahulu
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4. Riwayat Kesehatan Keluarga

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5. Genogram

6. Pemeriksaan Per Sistem

a. Sistem Pernapasan
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b. Sistem Kardiovaskuler
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c. Sistem Persyarafan
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d. Sistem Pencernaan
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e. Sistem Perkemihan
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f. Sistem Muskuloskeletal
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g. Sistem Endokrin
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h. Sistem Sensori Persepsi
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i. Sistem Integumen
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j. Sistem Imun dan Hematologi
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k. Sistem Reproduksi
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7. Pola Fungsional Kesehatan
a. Oksigenasi
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b. Cairan dan Elektrolit
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c. Nutrisi
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d. Aman dan Nyaman
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e. Eliminasi
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f. Aktivitas dan Istirahat
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g. Psikososial
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h. Komunikasi
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i. Seksual
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j. Nilai dan Keyakinan
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k. Belajar
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8. Pemeriksaan Penunjang
Pemeriksaan Hasil Normal
 9. Program terapi
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D. Analisa data
No Data Fokus Etiologi Problem
E. Prioritas Diagnosa Keperawatan
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F. Intervensi Keperawatan
No. Diagnosa Tujuan Dan Kriteria
Hari/Tgl/jam Intervensi (NIC) Ttd
(DP) Hasil (NOC)
 No. Diagnosa Tujuan Dan Kriteria
Hari/Tgl/jam Intervensi (NIC) Ttd
(DP) Hasil (NOC)
G. Implementasi Keperawatan
Hari/tgl/jam No. DP Implementasi Respon pasien Ttd
H. Evaluasi
Hari/tgl/jam No. DP SOAP Ttd