format pengkajian keperawatan
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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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