PENGKAJIAN KEPERAWATAN

1. IDENTITAS
a. Perawat Yang Mengkaji
Nama : .......................................................................................................................
Tanggal Pengkajian : .......................................................................................................................
Jam Pengkajian : .......................................................................................................................
b. Pasien
Nama : .......................................................................................................................
Umur : .......................................................................................................................
Agama : .......................................................................................................................
Pendidikan : .......................................................................................................................
Alamat : .......................................................................................................................
Tanggal Masuk : .......................................................................................................................
Diagnosa Medis : .......................................................................................................................
c. Penanggung Jawab
Nama : .......................................................................................................................
Umur : .......................................................................................................................
Agama : .......................................................................................................................
Pendidikan : .......................................................................................................................
Pekerjaan : .......................................................................................................................
Status : .......................................................................................................................
Alamat : .......................................................................................................................
Hub. Dengan Pasien : .......................................................................................................................

2. KELUHAN UTAMA

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3. KELUHAN YANG MENYERTAI

a. ............................................................................................................................................................
b. ............................................................................................................................................................
c. ............................................................................................................................................................

4. RIWAYAT KESEHATAN
a. Alasan Masuk Rumah Sakit

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 b. Riwayat Penyakit Saat Ini

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c. Riwayat Penyakit Dahulu (Penyakit Jiwa, Pengobatan, Perilaku Kekerasan, dll )

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d. Riwayat Penyakit Keluarga

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5. RIWAYAT PSIKOSOSIAL
a. Genogram

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b. Konsep Diri
1) Citra Tubuh : .................................................................................................................................
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2) Identitas : .................................................................................................................................
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3) Peran : .................................................................................................................................
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 4) Ideal Diri : .................................................................................................................................
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5) Harga Diri : .................................................................................................................................

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C. Hubungan Sosial
a. Orang Terdekat

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b. Peran Serta Dalam Kegiatan Kelompok

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c. Hambatan Dalam Berhubungan Dengan Orang Lain

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d. Spiritual
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6. PEMERIKSAAN FISIK
a. Keluhan Fisik

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b. Tanda-Tanda Vital

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7. STATUS MENTAL
a. Penampilan

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b. Pembicaraan

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c. Aktifitas Motorik

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d. Alam Perasaan

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e. Efek

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f. Istirahat dan Tidur

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g. Penggunaan Obat

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h. Pemeliharaan Kesehatan

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8. MEKANISME KOPING

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9. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
a. Masalah Dengan Dukungan Kelompok

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b. Masalah Dengan Pendidikan

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c. Masalah Dengan Perumahan

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d. Masalah Dengan Ekonomi

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e. Masalah Dengan Pelayanan Kesehatan

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10.ASPEK MEDIK
a. Diagnosa Medik

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b. Terapi Medik

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c. Pemeriksaan Penunjang

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 KLASIFIKASI DATA

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 ANALISA DATA

NO DATA ETIOLOGI MASALAH

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 DIAGNOSA KEPERAWATAN

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 INTERVENSI KEPERAWATAN

NO KODE NOC NIC

DX

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 IMPLEMENTASI DAN EVALUASI

NO HARI / IMPLEMENTASI JAM EVALUASI

TGL

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 DAFTAR PUSTAKA

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 INTERVENSI KEPERAWATAN

NO KODE NOC NIC

DX

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 IMPLEMENTASI DAN EVALUASI

NO HARI / IMPLEMENTASI JAM EVALUASI

TGL

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ANALISA DATA

NO DATA ETIOLOGI MASALAH

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