PROGRAM STUDI PROFESI NERS

STIKes FORT DE KOCK BUKITTINGGI

FORMAT PENGKAJIAN EVALUASI AKHIR NERS SIKLUS

PROGRAM PENDIDIKAN PROFESI (Ners)
KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa : Sri Novrika, S.Kep

Tanggal Ujian :

I. Identitas diri klien

Nama :
Tempat/tgl lahir :
Umur :
Jenis kelamin :
Tgl masuk RS :

II. Status Kesehatan Saat ini

1. Alasan kunjungan/keluhan
utama : .......................................................................................................................
....................................................................................................................................
.............
2. Faktor
pencetus : ...................................................................................................................
....................................................................................................................................
....................................................................................................................................
.................

III. Patofisiologi
IV. Pemeriksaan Fisik

V. Data Penunjang dan Pemeriksaan Diagnostik

Tanggal :

VI. Pengobatan
Tanggal :
VII. Analisa Data

Data Etiologi Masalah Keperawatan

Diagnosa Keperawatan :
 a. .....................................................................................................................................
b. .....................................................................................................................................
c. .....................................................................................................................................

VIII. Perencanaan
Diagnosa 1
.....................................................................................................................................
Tujuan
.....................................................................................................................................
.....................................................................................................................................
Kriteria Hasil :
.....................................................................................................................................
.....................................................................................................................................
Intervensi :
1. ...............................................................................................................................
Rasional :
...............................................................................................................................
2. ...............................................................................................................................
Rasional :
...............................................................................................................................
3. ...............................................................................................................................
Rasional :
...............................................................................................................................
4. ...............................................................................................................................
Rasional :
...............................................................................................................................
5. ...............................................................................................................................
Rasional :
...............................................................................................................................

Diagnosa 2
.....................................................................................................................................
Tujuan
.....................................................................................................................................
.....................................................................................................................................
Kriteria Hasil :
.....................................................................................................................................
.....................................................................................................................................
Intervensi :
1. ...............................................................................................................................
Rasional
...............................................................................................................................
2. ...............................................................................................................................
Rasional
...............................................................................................................................
3. ...............................................................................................................................
Rasional
...............................................................................................................................
4. ...............................................................................................................................
Rasional
...............................................................................................................................
5. ...............................................................................................................................
Rasional
...............................................................................................................................

Diagnosa 3
.....................................................................................................................................
 Tujuan
.....................................................................................................................................
.....................................................................................................................................
Kriteria Hasil :
.....................................................................................................................................
.....................................................................................................................................
Intervensi :
1. ...............................................................................................................................
Rasional
...............................................................................................................................
2. ...............................................................................................................................
Rasional
...............................................................................................................................
3. ...............................................................................................................................
Rasional
...............................................................................................................................
4. ...............................................................................................................................
Rasional
...............................................................................................................................
5. ...............................................................................................................................
Rasional
...............................................................................................................................

IX. Implementasi
Diagnosa 1

 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................

Diagnosa 2

 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................

Diagnosa 3

 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................
 ....................................................................................................................................

X. Evaluasi
Diagnosa 1 :
S :
O :
A :
P :

Diagnosa 2 :
S :
O :
A :
P :

Diagnosa 3 :
S :
O :
A :
P :