FORMAT PENGKAJIAN KESEHATAN
UJIAN PRAKTEK
Nama Klien : No.
RM :
Umur : Dx.
Medis :
A. PENGKAJIAN
- Riwayat.Kesehatan......................................................................................................................
1.
RKS............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................
2.
RKD....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3.
RKK..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2.PENGKAJIAN
FUNGSIONAL GORDON
·
Pola
Persepsi dan Penanganan Kesehatan ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................
·
Pola Nutrisi
& Metabolik ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pola
Eliminasi ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pola
Aktivitas-Latihan ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pola
Istirahat & Tidur ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pola
Kognitif dan Persepsi ........................................................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................
·
Pola Persepsi Diri-Konsep Diri
..................................................................................................................................................
..................................................................................................................................................
......................................................................................................................................................................................................................................................................................................
·
Pola
Peran Hubungan ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pola
Seksualitas-Reproduksi ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pola
Koping-Tolaransi Stess ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pola
Nilai- Kepercayaan ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PEMERIKSAAN FISIK
·
Tanda
Vital ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Kulit
dan Kepala ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Leher
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Thorak
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Jantung
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Abdomen
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Genetalia
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Rectal
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Muskuloskeletal
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PEMERIKSAAN PENUNJANG
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
WEB OF COUTION (WOC)
CATATAN PERKEMBANGAN
Hari / tanggal :
................................................. Ruangan : .......................
Nama :
................................................. No.
RM : .......................
|
Diagnosa
Keperawatan
|
Implementasi
|
Evaluasi
|
Perawat
& Paraf
|
|
|
|
|
|
ANALISA DATA
|
No
|
DATA
|
DIAGNOSA
|
|
|
|
|
NURSING
OUTCOMES & INTERVENTION CLASSIFICATION
|
No
|
Diagnosa
Keperawatan (NANDA)
|
Perencanaan
|
|
|
NOC
|
NIC
|
||
|
|
|
|
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