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    PENGKAJIAN KEPERAWATAN

    “SISTER CALLISTA ROY”

    Masuk Rumah Sakit : ..................................................................................................................


    Data Umum

    Tanggal Pengkajian : ..................................................................................................................


    Diagnosa Masuk : ..................................................................................................................
    D/ Saat Pengkajian : ..................................................................................................................

    Nama Pasien : ..................................................................................................................


    Jenis Kelamin : ..................................................................................................................
    Usia : ..................................................................................................................
    Identitas Diri

    Pendidikan : ..................................................................................................................
    Suku/ Bangsa : ..................................................................................................................
    Agama : ..................................................................................................................
    Status Kawin : ..................................................................................................................
    Pekerjaan : ..................................................................................................................
    Alamat : ..................................................................................................................

    TAHAP – I TAHAP – II
    1.1 Oksigenasi
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive
    TAHAP – I TAHAP – II
    1.2 Nutrisi
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive

    TAHAP – I TAHAP – II
    1.3 Eliminasi
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive
    TAHAP – I TAHAP – II
    1.4 Aktivitas dan Istirahat
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive

    TAHAP – I TAHAP – II
    1.5 Proteksi/ Perlindungan
    Stimuli Focal
    1. Fungsional

    Stimuli Kontekstual

    Stimuli Residual

     Adaptive
     Maladaptive
    TAHAP – I TAHAP – II
    1.6 Sense
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive

    TAHAP – I TAHAP – II
    1.7 Cairan dan Elektrolit
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive
    TAHAP – I TAHAP – II
    1.8 Neurologi
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive

    TAHAP – I TAHAP – II
    1.9 Neurologi
    Stimuli Focal

    Stimuli Kontekstual
    1. Fungsional

    Stimuli Residual

     Adaptive
     Maladaptive
    TAHAP – I TAHAP – II
    2.1 The Physical Self
    Stimuli Focal

    Stimuli Kontekstual
    2. Model Konsep

    Stimuli Residual

     Adaptive
     Maladaptive

    TAHAP – I TAHAP – II
    2.1 The Personal Self
    Stimuli Focal

    Stimuli Kontekstual
    2. Model Konsep

    Stimuli Residual

     Adaptive
     Maladaptive
    TAHAP – I TAHAP – II
    Stimuli Focal
    2. Model Fungsi Peran

    Stimuli Kontekstual

    Stimuli Residual

     Adaptive
     Maladaptive

    TAHAP – I TAHAP – II
    Stimuli Focal
    3. Model Interdependensi

    Stimuli Kontekstual

    Stimuli Residual
     Adaptive
     Maladaptive
    Test Diagnostik

    Therapy

    ........................., ..................................................
    Perawat yang Mengkaji,

    (...................................)
    IDENTIFIKASI DIAGNOSA KEPERAWATAN
    “NANDA”

    Data Etiologi Masalah


    Tgl
    PRIORITAS DIAGNOSA KEPERAWATAN

    DIAGNOSA KEPERAWATAN
    No.

    ........................., ..................................................
    Perawat yang Mengkaji,

    (...................................)
    INTERVENSI KEPERAWATAN

    Tgl , Nama
    No. DP Hasil Yang Diharapkan Rencana Keperawatan Perawat

    Meningkatkan Respon Adaptif


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    IMPLEMENTASI & EVALUASI

    Nama
    Tgl. Implementasi Nama Evaluasi Perawat
    Pkl. Perawat

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