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FORMAT PENGKAJIAN

APLIKASI TEORI MODEL KONSEP ADAPTASI ROY


STIKES HANG TUAH SURABAYA

A. PENGKAJIAN
1. Identitas Klien
a. Nama : ........................................................................................................................
b. Jenis kelamin : L/P
c. Umur : .......... tahun
d. Agama : ........................................................................................................................
e. Pendidikan : .............................................................................................
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f. Pekerjaan : .........................................................................................................
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g. Suku : ........................................................................................................................
h. Alamat: ........................................................................................................................

2. Pengkajian Tahap pertama


a. Fisiologi
1) Oksigenasi dan ventilasi
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2) Nutrisi
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3) Eliminasi
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4) Aktivitas
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5) Istirahat
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6) Sense
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7) Cairan, elektrolit, dan keseimbangan asam basa
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8) Fungsi neurologis
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9) Endokrin
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b. Konsep diri
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c. Fungsi peran
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d. Ketergantungan
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3. Pengkajian Tahap Kedua
Mode fisiologi
Perilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

Konsep diri
Perilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

Fungsi Peran
Perilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

Interdependensi
Perilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

B. DIAGNOSA KEPERAWATAN
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RENCANA DAN TINDAKAN KEPERAWATAN
No. Dx Tujuan Intervensi
IMPLEMENTASI DAN EVALUASI
No. Dx Implementasi Evaluasi