A.

PENGKAJIAN
1. PENGUMPULAN DATA
a. Identitas
1) Nama : ...............................................................................
2) Jenis Kelamin : ...............................................................................
3) Umur : ...............................................................................
4) Status Perkawinan : ...............................................................................
5) Pekerjaan : ...............................................................................
6) Agama : ...............................................................................
7) Pendidikan Terakhir : ...............................................................................
8) Alamat : ...............................................................................
9) Tanggal MRS : ...............................................................................
10) No. Register : ................................................................................

b. Diagnosa Medis
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c. Keluhan Utama (Saat Pengkajian)

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d. Riwayat Penyakit Sekarang

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e. Riwayat Penyakit Lalu

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f. Riwayat Kesehatan Keluarga

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g. Pola Aktivitas
1) Makan dan Minum
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 2) Pola Eliminasi
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3) Pola Istirahat dan Tidur

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4) Kebersihan Diri
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h. Riwayat Psikososial
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i. Pemeriksaan Fisik
1) Keadaan Umum
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2) Tanda-Tanda Vital
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3) Pemeriksaan Kepala dan Leher

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 4) Pemeriksaan Integumen
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5) Pemeriksaan Dada dan Thorak

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6) Pemeriksaan Payudara
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7) Pemeriksaan Abdomen
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8) Pemeriksaan Genetalia
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9) Pemeriksaan Ekstrimitas
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j. Pemeriksaan Neurologis
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k. Pemeriksaan Penunjang
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 l. Terapi/Pengobatan/Penatalaksanaan
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Malang, ..............................
Mahasiswa

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Catatan:
2. ANALISIS DATA

Nama : Ruang :
Umur :
No. Register :

DATA FOKUS MASALAH ETIOLOGI

DATA FOKUS MASALAH ETIOLOGI
B. DIAGNOSA KEPERAWATAN

Nama : Ruang :
Umur :
No. Register :

DIAGNOSA KEPERAWATAN
C. PERENCANAAN ASUHAN KEPERAWATAN
1. PRIORITAS MASALAH

Nama : Ruang :
Umur :
No. Register :

NO. TANGGAL TANGGAL

DIAGNOSA KEPERAWATAN TTD
DX MUNCUL TERATASI
2. RENCANA ASUHAN KEPERAWATAN

Nama : Ruang : Dx. Medis:

Umur : Tanggal MRS :
No. Register :

NO. DIAGNOSA TUJUAN &

INTERVENSI RASIONAL
DX KEPERAWATN KRITERIA HASIL
NO. DIAGNOSA TUJUAN & KRITERIA
INTERVENSI RASIONAL
DX KEPERAWATN HASIL
D. IMPLEMENTASI ASUHAN KEPERAWATAN

Nama : Ruang : Dx. Medis:

Umur : Tanggal MRS :
No. Register :

NO. DX
TANGGAL PUKUL TINDAKAN TTD
KEP.
 NO. DX
TANGGAL PUKUL TINDAKAN TTD
KEP.
E. EVALUASI ASUHAN KEPERAWATAN
CATATAN PERKEMBANGAN

Nama : Ruang : Dx. Medis:

Umur : Tanggal MRS :
No. Register :

DINAS: DINAS: DINAS:

TANGGAL
Pukul Dx. Kep: Pukul Dx. Kep: Pukul Dx. Kep:
 DINAS: DINAS: DINAS:
TANGGAL
Pukul Dx. Kep: Pukul Dx. Kep: Pukul Dx. Kep: