I. IDENTITAS
1. Nama : .....................................................................................................................
2. Umur : .....................................................................................................................
3. Jenis kelamin : .....................................................................................................................
4. Status : .....................................................................................................................
5. Agama : .....................................................................................................................
6. Suku/bangsa : .....................................................................................................................
7. Bahasa : .....................................................................................................................
8. Pendidikan : .....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat dan no. telp : .....................................................................................................................
11. Penanggung jawab : .....................................................................................................................
& hubgan dg klien
2. Kebersihan diri
Di rumah Di rumah sakit
Mandi : ........................ Mandi : ........................
/hr /hr
Gosok gigi : ........................ Gosok gigi : ........................
/hr /hr
Keramas : .................... Keramas : ....................
/mgg /mgg
Potong kuku : .................... Potong kuku : ....................
/mgg /mgg
3. Aktivitas sehari-hari
.........................................................................................................................................................
4. Rekreasi
.........................................................................................................................................................
.........................................................................................................................................................
5. Olahraga : ( ) tidak ( ) ya
.........................................................................................................................................................
Vertigo : ( ) tidak ( ) ya
Nyeri : ( ) tidak ( ) ya
.........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
2. Role/peran
( ) overload peran ( ) perubahan peran ( ) transisi peran karena sakit
( ) konflik peran ( ) keraguan peran
Jelaskan : ........................................................................................................................................
........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
3. Identity/identitas diri
( ) kurang percaya diri ( ) merasa kurang memiliki potensi
( ) merasa terkekang ( ) kurang mampu menentukan pilihan
( ) tidak mampu menerima perubahan ( ) menolak menjadi tua
Jelaskan : ........................................................................................................................................
........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
4. Self esteem/harga diri
( ) mengkritik diri sendiri dan orang lain ( ) merasa jadi orang penting
( ) menunda tugas ( ) polarisasi pandangan hidup
( ) merusak diri ( ) mencemooh diri
( ) menyangkal kemampuan pribadi ( ) mengecilkan diri
( ) rasa bersalah ( ) keluhan fisik
( ) menyangkal kepuasan diri ( ) menyalahgunakan zat
Jelaskan : .......................................................................................................................................
........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
5. Self ideal/ideal diri
( ) masa depan suram ( ) tidak ingin berusaha
( ) terserah pada nasib ( ) tidak memiliki cita-cita
( ) merasa tidak memiliki kemampuan ( ) merasa tidak berdaya
( ) tidak memiliki harapan ( ) enggan membicarakan masa depan
Jelaskan : ...........................................................................................................................................
...........................................................................................................................................
Masalah keperawatan : ......................................................................................................................
..................................................................................................................................
Masalah keperawatan : .............................................................................................................
b. Tahap Anger/Marah
( ) marah pada diri sendiri ( ) meningkatnya kesadaran klien pada
( ) marah pada orang lain realita
Jelaskan : .................................................................................................................................
..................................................................................................................................
Masalah keperawatan : .............................................................................................................
3. Kemampuan adaptasi
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XV. TERAPI
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ANALISA DATA
Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama perawat)
RENCANA KEPERAWATAN