Prodi Profesi Ners

FIK UNIPDU Jombang

Nama Mahasiswa : _______________________

NIM : _______________________
Tanggal Ujian : _______________________
Ruangan : _______________________

PENGKAJIAN
I. BIODATA
Nama : _________________________________________________
Umur : _________________________________________________
Agama : _________________________________________________
Alamat : ________________________________________________
Pendidikan : ________________________________________________
Pekerjaan : ________________________________________________
Tanggal MRS : _______________________________________________
Diagnosa Medis : _______________________________________________
Nomor Register : _______________________________________________
Tanggal Pengkajian : ______________________________________________

II. KELUHAN UTAMA

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III. RIWAYAT PENYAKIT SEKARANG

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IV. RIWAYAT PENYAKIT MASA LALU

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Praktik KMB - Prodi Profesi Ners FIK UNIPDU Jombang 1
 V. RIWAYAT KESEHATAN KELUARGA
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VI. POLA AKTIVITAS SEHARI-HARI :

1. Pola tidur/Istirahat :
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2. Pola Eliminasi :
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3. Pola makan/minum :
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4. Pola Kebersihan diri :

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5. Pola Kegiatan/kebiasaan lain :
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6. Pola Hubungan Peran ( Konsep Diri ) :
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Praktik KMB - Prodi Profesi Ners FIK UNIPDU Jombang 2

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7. Pola Seksual :
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8. Pola Penanggulangan Stress :

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VII. DATA PSIKOSOSIAL

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VIII. DATA SPIRITUAL
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IX. PEMERIKSAAN FISIK

A. Keadaan umum :
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B. Tanda-tanda vital :
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Praktik KMB - Prodi Profesi Ners FIK UNIPDU Jombang 3

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C. Pemeriksaan kepala dan leher :

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D. Mata :
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E. Hidung :
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F. Telinga :
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G. Mulut :
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H. Integumen :
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Praktik KMB - Prodi Profesi Ners FIK UNIPDU Jombang 4

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I. Thorak/dada :
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J. Abdomen :
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K. Kelamin dan daerah sekitarnya :

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L. Muskuloskeletal :
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M. Neurologi :
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X. PEMERIKSAAN PENUNJANG :

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XI. PENATA LAKSANAAN/TERAPI

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PERAWAT

( __________________________)
NIM :

ANALISA DATA
Nama Klien : ________________ Dx. Medis : ________________

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No. Register : ________________ Ruangan : ________________

No Kelompok Data Kemungkinan Penyebab Masalah

DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS

Nama Klien : ________________ Dx. Medis : ________________

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No. Register : ________________ Ruangan : ________________

No Diagnosa Perawatan Tanggal TTD

Ditemukan Teratasi

CATATAN KEPERAWATAN
Nama Klien : ________________ Dx. Medis : ________________

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No. Register : ________________ Ruangan : ________________

Tgl / Jam No. Dx. Tindakan Perawatan Respon Klien TTD

CATATAN PERKEMBANGAN
Nama Klien : ________________ Dx. Medis : ________________

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No. Register : ________________ Ruangan : ________________

Tanggal Jam No. Dx. Catatan Perkembangan TTD

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 RENCANA KEPERAWATAN
Nama Klien : ________________ Dx. Medis : ________________
No. Register : ________________ Ruangan : ________________

DIAGNOSA
NO. TUJUAN KRITERIA / RENCANA TINDAKAN(NIC) RASIONAL
KEPERAWATAN
STANDART(NOC)

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