Oleh:
Nama : ………………………….
NIM : ………………………….
B. Pengertian
E. Pemeriksaan Diagnostik
F. Penatalaksanaan Medis
G. Pengkajian Keperawatan
J. Referensi
IDENTITAS KLIEN
1. Nama:
2. Jenis Kelamin :
3. Umur:
4. Status Kawin :
5. Suku/ Bangsa :
6. Agama :
7. Pendidikan :
8. Pekerjaan :
9. Alamat :
10. Sumber Biaya :
KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
5. Lain-lain:
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis :
………………….....................................................................................................................................
- Genogram :
Jenis................................................ Flow..............lpm
j. Penggunaan WSD:
- Jenis : .....................................................................................................................................................
............
- Jumlah cairan
: ..................................................................................................................................................
- Undulasi :........................................................................................................................................
...........
- Tekanan : .......................................................................................................................................
...........
k. Tracheostomy: ya tidak
......................................................................................................................................................................
......................................................................................................................................................................
l. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
b. Tes Audiometri
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
TERAPI MEDIS
....................................................................................................................................................................................
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Malang, 2019
(……………………………)
ANALISA DATA
Nama Pasien :
Umur :
No. Register :
Hari/
Tgl/ DATA ETIOLOGI MASALAH
Jam
DIAGNOSA KEPERAWATAN
Nama Pasien :
Umur :
No. Register :
1.
2.
3.
4.
PRIORITAS MASALAH KEPERAWATAN
Nama Pasien :
No. Register :
No TANGGAL TANGGAL TANDA
DIAGNOSA KEPERAWATAN
DX MUNCUL TERATASI TANGAN
RENCANA ASUHAN KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ DIAGNOSA
No NOC NIC
Tgl/ KEPERAWAT
. (Nursing Outcome Classification) (Nursing Intervention Classification)
Jam AN
IMPLEMENTASI
Nama Pasien :
No. Register :
Hari/
Tgl/ Diagnosa Kep. Jam Implementasi Paraf
Shift
EVALUASI
Nama Pasien :
No. Register :
Hari/ Tgl/ Para
Diagnosa Kep. Jam Evaluasi
Shift f
FORMAT RESUME
I. BIODATA
Nama : …………………………………………………………………
Jenis kelamin ; …………………………………………………………………
Umur : …………………………………………………………………
Status Perkawinan : …………………………………………………………………
Pekerjaan : …………………………………………………………………
Agama : …………………………………………………………………
Pendidikan Terakhir : …………………………………………………………………
Alamat : …………………………………………………………………
Tanggal MRS : …………………………………………………………………
Tanggal Pengkajian : …………………………………………………………………
1. Keluhan utama
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………
2. Riwayat Kesehatan Sekarang
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………
3. Riwayat kesehatan yang lalu
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………
4. Riwayat kesehatan keluarga
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………
V. IMPLEMENTASI
TGL PUKUL NO Dx.KEP IMPLEMENTASI TT
VI. EVALUASI
TGL
Dx.KEP DATA (soapier)
/ PUKUL
Subyektif
Obyektif
Assesment
Planning
Implementasi
Reassesment