FORMAT PENGKAJIAN KEPERAWATAN

Tanggal masuk : ...............................................

No. RM :................................................

1. IDENTITAS
Nama : ........................................................................
Alamat : ........................................................................
Pekerjaan : ........................................................................
Penanggung Jawab : ........................................................................
Status Perkawinan : Kawin/Tidak Kawin/Janda, Duda

Keluarga terdekat yang segera dihubungi :

Nama : ........................................................................
Hubungan : ........................................................................
Pekerjaan : ........................................................................
Alamat : ........................................................................
No telp. : ........................................................................

2. RIWAYAT KESEHATAN
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Alasan datang ke
RS : .....................................................................................................................................................
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Diagnosa
Medis : ................................................................................................................................................
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Penyakit yang pernah
dialami : ..............................................................................................................................................
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Macam obat yang diminum sekarang Dosisi
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POLA FUNGSI KESEHATAN GORDON

1. Pola Persepsi Kesehatan / Penanganan Kesehatan
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2. Pola Nutrisi Dan Metabolik

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3. Pola Eliminasi
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4. Pola Aktivitas Dan Latihan
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5. Pola Istirahat Dan Tidur
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6. Pola Kognitif Dan Perseptual
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7. Pola Persepsi Diri / Konsep Diri
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8. Pola Hubungan / Peran
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9. Pola Seksualitas / Reproduksi
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10. Pola Koping / Toleransi Stress
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11. Pola Nilai Dan Kepercayaan
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