FORMAT Pengkajian KDP
FORMAT Pengkajian KDP
4. DIAGNOSA KEPERAWATAN
5. INTERVENSI KEPERAWATAN DAN RASIONAL
6. DAFTAR PUSTAKA
I. PENGKAJIAN
1. IDENTITAS PASIEN
2. RIWAYAT KEPERAWATAN
3. OBSERVASI DAN PEMERIKSAAN FISIK (BODY SYSTEM/HEAD TO
TOE)
4. DIAGNOSTIC TEST
5. ANALISA DAN SINTESA DATA
IV. IMPLEMENTASI
V. EVALUASI
FORMAT PENGAKJIAN KEPERAWATAN
I. IDENTITAS
Nama : ..............................................................................................
Umur : ..............................................................................................
Pekerjaan : ..............................................................................................
Tanggal MRS : ..............................................................................................
Alamat : ..............................................................................................
Masalah Keperawatan:
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3. Riwayat kesehatan keluarga
a. Penyakit yang pernah diderita oleh anggota keluarga :
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Lingkungan rumah dan komunitas ..........................................................................
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b. Perilaku yang mempngaruhi kesehatan
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c. Persepsi terhadap penyakit
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Masalah Keperawatan:
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4. Kesadaran :
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5. Tanda- Tanda Vital :
Suhu : ...............................................................................
TD : ...............................................................................
RR : ...............................................................................
Nadi : ................................................................................
6. Genogram (3 generasi)
III. POLA FUNGSI KESEHATAN
1. Pola penatalaksanaan kesehatan / persepsi sehat
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Masalah Keperawatan :
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3. Pola Eliminasi
Eliminasi Alvi
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Eliminasi Uri
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Masalah Keperawatan :
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Pola persepsi
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Konsep diri
a. Gambaran diri
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b. Harga diri
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c. Ideal diri
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d. Peran diri
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e. Identitas diri
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Masalah Keperawatan :
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8. Pola Reproduksi Seksual
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Masalah Keperawatan :
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Masalah Keperawatan :
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Biceps Triceps
\ \
Knee Achiles
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Babinski Oppenheim
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Dextra Sinistra
Masalah Keperawatan :
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Masalah Keperawatan :
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1. Pemeriksaan Laboratorium
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2. Pemeriksaan Radiologi
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10……………………………………………………………………………………
Surabaya,
Preceptee
(……………………….)
ANALISA DATA