FORMAT PENGKAJIAN KEPERAWATAN DASAR

Data diambil tanggal : ……………………………………………

Ruang rawat/kelas : ……………………………………………
No. Rekam Medik : ……………………………………………

I. IDENTITAS
Nama : ..............................................................................................

Umur : ..............................................................................................

Jenis kelamin : ..............................................................................................

Pekerjaan : ..............................................................................................
Tanggal MRS : ..............................................................................................

Alamat : ..............................................................................................

Diagnosa medis : ..............................................................................................

Sumber informasi : .............................................................................................

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

II. RIWAYAT KEPERAWATAN

1. Riwayat keperawatan sekarang
a. Keluhan utama
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b. Riwayat penyakit saat ini

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2. Riwayat keperawatan/Penyakit sebelumnya
a. Riwayat kesehatan yang lalu :
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Masalah Keperawatan:
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3. Riwayat kesehatan keluarga

a. Penyakit yang pernah diderita oleh anggota keluarga :
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Lingkungan rumah dan komunitas
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b. Perilaku yang mempngaruhi kesehatan
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c. Persepsi terhadap penyakit
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Masalah Keperawatan:
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4. Kesadaran :
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 5. Tanda- Tanda Vital :
Suhu : ...............................................................................
TD : ...............................................................................
RR : ...............................................................................
Nadi : ................................................................................

6. Genogram (3 generasi)

III. POLA FUNGSI KESEHATAN

1. Pola penatalaksanaan kesehatan / persepsi sehat
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Masalah Keperawatan :
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2. Pola Nutrisi– Metabolik

Data Subyektif:
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Data Obyektif:
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Masalah Keperawatan :
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3. Pola Eliminasi
Eliminasi Alvi
Data Subyektif:
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Data Obyektif:
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Eliminasi Uri
Data Subyektif:
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Data Obyektif:
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Masalah Keperawatan :
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4. Pola Istirahat dan tidur

Data Subyektif:
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Data Obyektif:
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Masalah Keperawatan :
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5. Pola Aktifitas - Latihan
Data Subyektif:
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Data Obyektif:
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Masalah Keperawatan :
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6. Pola kognitif – perseptual – keadekuatan alat sensori

Data Subyektif:
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Data Obyektif:
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Masalah Keperawatan :
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7. Pola persepsi dan konsep diri

Pola persepsi
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Konsep diri
a. Gambaran diri
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b. Harga diri
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c. Ideal diri
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d. Peran diri
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e. Identitas diri
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Masalah Keperawatan :
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8. Pola Reproduksi Seksual
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Masalah Keperawatan :
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9. Pola hubungan peran

Persepsi klien tantang pola hubungan

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Persepsi klien tentang peran dan tanggung jawab

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Masalah Keperawatan :
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10. Mekanisme Koping

Kemampuan mengendalian stress

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Sumber pendukung
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Masalah Keperawatan :
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11. Pola tata nilai dan kepercayaan

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Masalah Keperawatan :
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12. Pemeriksaan Refleks

Refleks : Fisilogis

Dextra Sinistra Dextra Sinistra

Biceps Triceps
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Dextra Sinistra Dextra Sinistra

Knee Achiles
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Refleks Patologis Dextra Sinistra Dextra Sinistra

Babinski Oppenheim
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Dextra Sinistra

Chadok
 Masalah Keperawatan :
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13. Aspek Sosial

a. Ekspresi efek dan emosi : Senang Sedih

Menangis
Cemas Marah Diam
Takut Lain ...................................
b. Hubungan dengan keluarga :
Akrab Kurang akrab

Masalah Keperawatan :
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14. Pemeriksaan Penunjang

1. Pemeriksaan Laboratorium
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2. Pemeriksaan Radiologi
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 3. Pemeriksaan Lain – lain
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4. Terapi dan Diet.

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DAFTAR MASALAH KEPERAWATAN

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Surabaya,
Preceptee

(……………………….)
 ANALISA DATA

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

DATA ETIOLOGI PROBLEM

 DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :
NO DIAGNOSA KEPERAWATAN TTD
 RENCANA KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

NO DIAGNOSA TUJUAN KRITERIA HASIL INTERVENSI RASIONAL

KEPERAWATAN
 IMPLEMENTASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TANGGAL / JAM IMPLEMENTASI TTD

 EVALUASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TGL / DIAGNOSE EVALUASI

JAM KEPERAWATAN