SOEPRAOEN
PROGRAM STUDI KEPERAWATAN
NAMA MAHASISWA :
NIM :
RUANG :
A. PENGKAJIAN
1. Riwayat Keperawatan
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2. Pemeriksaan Fisik
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3. Pemeriksaan Diagnostik
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B. DIAGNOSA KEPERAWATAN
C. PERENCANAAN
D. PELAKSANAAN
E. EVALUASI
SUMBER/REFERENSI:
1
POLITEKNIK KESEHATAN RS dr. SOEPRAOEN
PROGRAM STUDI KEPERAWATAN
A. Identitas Klien
Nama : No. RM :
Status pernikahan :
Agama : Status :
Suku : Alamat :
Pekerjaan : Pendidikan :
Diagnosa Medis:
2
C. Riwayat Kesehatan Saat Ini
F. Genogram
3
G. Riwayat Lingkungan
Jenis Rumah Pekerjaan
Kebersihan
Bahaya Kecelakaan
Polusi
Ventilasi
Pencahayaan
-
Palpasi :..................................................................................................................................
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- Perkusi :...................................................................................................................................
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- Auskultasi : .............................................................................................................................
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Paru
- Inspeksi ..................................................................................................................................
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- Palpasi : ..................................................................................................................................
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- Perkusi : ..................................................................................................................................
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- Auskultasi : .............................................................................................................................
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4. Payudara & Ketiak
Benjolan/massa : ..........................................................................................................................
Bengkak : ......................................................................................................................................
Nyeri : ...........................................................................................................................................
Nyeri tekan : ................................................................................................................................
7
Kesimetrisan : ...............................................................................................................................
5. Punggung & Tulang Belakang
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6. Abdomen
Inspeksi ............................................................................................................................................
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Palpasi...............................................................................................................................................
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Perkusi..............................................................................................................................................
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Auskultasi..........................................................................................................................................
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Malang,
Pengkaji
__________________
ANALISA DATA
9
DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN
NAMA KLIEN :
NO.REG :
10
11
RENCANA ASUHAN KEPERAWATAN
12
Nama : __________________ Ruangan : ______________________ RM No. : _____________________Dx medis : _____________________
No. Tanggal/
IMPLEMENTASI KEPERAWATAN EVALUASI
Dx Jam
13
14