format pengkajian keperawatan

FORMAT PENGKAJIAN KEPERAWATAN

AKADEMI KEPERAWATAN JABAL GHAFUR SIGLI

NAMA :

NIM :

1. IDENTITAS PASIENNama Pasien :

Umur :

Jenis Kelamin :

Suku :

Agama :

Pekerjaan :

Pendidikan :

Tanggal Masuk :

Alamat :

Diagnose Medik :

2. RIWAYAT PENYAKIT a. Keluhan Utama

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b. Riwayat Penyakit Sekarang ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. Riwayat Penyakit Yang Lalu............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

d. Riwayat Penyakit Keluarga

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3. Pola Kebiasaan Sehari-Hari (Sebelum Dan Selama Sakit )a. Pola Makan / Minum

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b. Pola Istirahat / Tidur....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. Pola Eliminasi....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

d. Pola Aktifitas ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Data Psikologi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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5. Data Sosial..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

6. Data Spiritual.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

7. Patofisiologis Diagnose Medik.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

8. Pemeriksaan Fisik

B. RENCANA KEPERAWATAN

Nama : Ruang rawat : Umur : Diagnosa Medis :Tanggal Masuk : No. CM :

No Tanggal/ jam Dx Keperawatan Tujuan/ Kriteria hasil Rencana Keperawatan Implementasi EnaluasiIntervensi Rasionalisasi

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