A. PENGKAJIAN
1. Data Umum
Identitas Klien
Nama : .................................................. ................................
Umur : .................................................. ................................
Agama : ................................................. .................................
Jenis Kelamin : .................................................. ................................
Status Marital : ................................................... ...............................
Pendidikan : .................................................. ................................
Pekerjaan : .................................................. ................................
Suku Bangsa : ................................................. .................................
Alamat : ................................................. .................................
Tanggal Masuk : .................................................. ................................
Tanggal Pengkajian : .................................................. ................................
No. Register : .................................................. ................................
Diagnosa Medis : ................................................. .................................
2. Riwayat Kesehatan
Keluhan Utama
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Riwayat Penyakit Sekarang
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Riwayat Kesehatan Dahulu
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Riwayat Kesehatan Keluarga
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Genogram :
2
Riwayat Sosiokultural
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3. PEMERIKSAAN FISIK
a. Keadaan Umum
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b. Tanda Vital
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c. Kepala
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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. Leher.........................................................................................................
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i. Dada dan Punggung
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j. Abdomen
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k. Ekstremitas
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l. Genetalia
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m. Anus
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h. Pola Peran-Hubungan
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i. Pola Seksual-Reproduksi
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j. Pola Toleransi Stress-Koping
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k. Pola Nilai-Kepercayaan
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7. DATA TAMBAHAN
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B. ANALISA DATA
NO. DIAGNOSIS
KEPERAWATAN
D. IMPLEMENTASI
KEPERAWATAN
Hari/
No Dx
Tgl/Jam
E. EVALUASI
KEPERAWATAN
No Hari/Tgl No