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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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