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:
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RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
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- Genogram :
Jenis................................................ Flow..............lpm
j. Penggunaan WSD:
- Jenis :
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- Jumlah cairan :
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- Undulasi :
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- Tekanan :
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k. Tracheostomy: ya tidak
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l. Lain-lain:
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8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach
b. Tes Audiometri
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b. Warna
c. Pitting edema: +/- grade:................
Masalah Keperawatan :
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
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PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
TERAPI MEDIS
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Malang, 2020
(……………………………)
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 DIAGNOSA TANGGAL TANDA
DX MUNCUL KEPERAWATAN TERATASI TANGAN
RENCANA ASUHAN KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ Tgl/ DIAGNOSA NOC NIC
No.
Jam KEPERAWATAN (Nursing Outcome Classification) (Nursing Intervention Classification)
IMPLEMENTASI
Nama Pasien :
No. Register :
Hari/
Tgl/ Diagnosa Kep. Jam Implementasi Paraf
Shift
EVALUASI
Nama Pasien :
No. Register :
Hari/
Tgl/ Diagnosa Kep. Jam Evaluasi Paraf
Shift
Lampiran 2 Lembar bimbingan KTI
Lampiran 3 Plan of Action
Lampiran 4 Surat Izin Penelitian dan Surat Keterangan Selesai Penelitian
Lampiran 5 Absensi penelitian
Lampiran 6 Penjelasan sebelum penelitian
Lampiran 7 Informed consent