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    wendihi
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    Judul Asli

    FORMAT PENGKAJIAN LK

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    5 tayangan11 halaman

    Format Pengkajian LK

    Diunggah oleh

    wendihi

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 11

    FORMAT PENGKAJIAN

    KEPERAWATAN DASAR PROFESI


    JURUSAN KEPERAWATAN POLTEKKES KEMENKES BENGKULU

    Nomor MR :.................................. Dignosa Medis :.................................

    Jaminan Rawat :Umum/Askes/........... Tanggal masuk RS :.................................

    Ruang Rawat :.................................. Tanggal Pengkajian:.................................

    A. PENGKAJIAN ANAMNESA
    FORMAT ASUHAN KEPERAWATAN
    Tanggal Pengkajian/Jam :.................................... Ruang/RS:...............................
    1. BIODATA
    a. Biodata Pasien
    Nama :...................................................................
    Umur :...................................................................
    Alamat :...................................................................
    Pendidikan :...................................................................
    Pekerjaan :...................................................................
    Tanggal Masuk RS :...................................................................
    Diagnosa Medis :...................................................................
    No.Rekam Medis :...................................................................

    b. Biodata Penanggung Jawab


    Nama :...................................................................
    Umur :...................................................................
    Alamat :...................................................................
    Pendidikan :...................................................................
    Pekerjaan :...................................................................
    Hubungan dengan Klien :...................................................................

    2. KELUHAN UTAMA
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    3. RIWAYAT KESEHATAN
    a. Riwayat Kesehatan Sekarang
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    b. Riwayat Kesehatan Dahulu
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    c. Riwayat Kesehatan Keluarga
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    4. PENGKAJIAN POLA FUNGSIONAL (Contoh: GORDON)


    a. Pola manajemen dan persepsi kesehatan
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    b. Pola nutrisi dan metabolisme
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    c. Pola eliminasi
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    d. Pola istirahat dan tidur
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    e. Pola aktivitas dan latihan
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    f. Pola peran dan hubungan
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    g. Pola persepsi kognitif dan sensori
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    h. Pola persepsi diri/Konsep diri
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    i. Pola seksual dan reprosuksi
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    j. Pola mekanisme koping
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    k. Pola nilai dan kepercayaan
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    5. PEMERIKSAAN FISIK (mengacu pada topik yang diambil)


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    6. PEMERIKSAAN DIAGNOSTIK
    a. Laboratorium
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    b. Radiologi
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    ..
    c. dll
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    7. PROGRAM TERAPI
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    DAFTAR MASALAH

    No Tanggal/ Data Fokus Etiologi Masalah


    Jam
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    RENCANA KEPERAWATAN

    No Tanggal/ Diagnosa Keperawatan/SDKI Tujuan/SLKI Intervensi/SIKI TTD


    Jam perawat
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    IMPLEMENTASI/TINDAKAN KEPERAWATAN

    Tanggal Diagnosa Keperawatan Tindakan Keperawatan TTD


    /Jam Perawat
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    CATATAN PERKEMBANGAN

    Tanggal Diagnosa Keperawatan Subjektif, Objektif, Analysis, TTD


    /Jam Planning Perawat
    (S-O-A-P)
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