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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V. RIWAYAT KESEHATAN KELUARGA
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VI. POLA AKTIVITAS SEHARI-HARI :

1. Pola Persepsi Kesehatan
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2. Pola Nutrisi Metabolik

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3. Pola Eliminasi
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4. Pola Aktivitas - Latihan

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5. Pola Istirahat Tidur
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6. Pola Kognitif Perseptual

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7. Pola Persepsi Diri

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8. Pola Peran Hubungan

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 9. Pola Seksualitas - Reproduksi
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10 . Pola Koping – Toleransi Stress

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11. Pola Milai Kepercayaan

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IX. PEMERIKSAAN FISIK

A. Keadaan umum :
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B. Tanda-tanda vital :
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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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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 :

XI. PENATA LAKSANAAN/TERAPI

MAHASISWA

( __________________________)
NIM :
 ANALISA DATA
Nama Klien : ________________ Dx. Medis : ________________
No. Register : ________________ Ruangan : ________________

No Kelompok Data Kemungkinan Penyebab Masalah

 DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS
Nama Klien : ________________ Dx. Medis : ________________
No. Register : ________________ Ruangan : ________________

No Diagnosa Perawatan Tanggal TTD

Ditemukan Teratasi
 CATATAN KEPERAWATAN
Nama Klien : ________________ Dx. Medis : ________________
No. Register : ________________ Ruangan : ________________

Tgl / Jam No. Tindakan Perawatan Respon Klien TTD

Dx.
 CATATAN PERKEMBANGAN
Nama Klien : ________________ Dx. Medis : ________________
No. Register : ________________ Ruangan : ________________

Tanggal Jam No. Dx. Catatan Perkembangan TTD

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

DIAGNOSA
NO. TUJUAN SLKI SIKI
KEPERAWATAN