Lampiran 2

FORMAT PENGKAJIAN PRAKTIK PROFESI KGD

PROGRAM STUDI PROFESI NERS UNIVERSITAS PAHLAWAN

A. INFORMASI UMUM
Tanggal Pengkajian : ____________________
B. IDENTITAS PASIEN
Nama : ____________________
Umur : ____________________
Agama : ____________________
Jenis Kelamin : ____________________
Pendidikan : ____________________
Pekerjaan : ____________________
Alamat : ____________________
Diagnosa Medis : ____________________
No RM : ____________________

C. RIWAYAT KESEHATAN
1. Alasan Masuk Rumah Sakit :
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2. Riwayat Kesehatan Sekarang
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3. Riwayat Kesehatan Dahulu
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D. PENGKAJIAN
1. Circulation
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2. Airway
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3. Breathing
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4. Disability
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5. Exposure
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E. PEMERIKSAAN FISIK
1. Tanda-tanda Vital
a. Tekanan Darah : __________________
b. Nadi : __________________
c. Suhu : __________________
d. Pernafasan : __________________
e. Berat Badan : __________________
f. Tinggi Badan : __________________

2. Kepala
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3. Leher
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4. Tangan
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5. Dada
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6. Abdomen
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7. Genitalia
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8. Kaki
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9. Punggung
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10. Neurosensori
a. Tingkat Kesadaran : _________________________
b. GCS : _________________________
c. Kekuatan Otot : _________________________

11. Intake Nutrisi dan Cairan

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F. PEMERIKSAAN LABORATORIUM

Jenis Pemeriksaan Hasil Nilai Normal

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G. PEMERIKSAAN DIAGNOSTIK LAINNYA

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H. MEDIKASI
Tanggal Pemberian : _________________
Jenis Obat-obatan :
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FORMAT INTERVENSI KEPERAWATAN

Nama Pasien : _________________ Nama Mahasiswa : _______________

Ruangan : _________________ NIM : _______________
No. RM : _________________
 Diagnosa Keperawatan : _________________________________________________
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Tujuan : _________________________________________________
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Kriteria Hasil : ________________________
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INTERVENSI RASIONAL

FORMAT IMPLEMENATSI & EVALUASI KEPERAWATAN

Nama Pasien : _________________ Nama Mahasiswa : _______________

Ruangan : _________________ NIM : _______________
No. RM : _________________

Diagnosa Keperawatan : _________________________________________________

TGL/JAM IMPLEMENTASI EVALUASI PARAF