PENGKAJIAN KEPERAWATAN
TANGGAL : NAMA PASIEN / UMUR
NAMA PERAWAT : NO MR
NIP : DIAGNOSA MEDIS
JABATAN : DPJP
A.Keluhan Utama saat masuk RS
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B.Riwayat penyakit sekarang ( saat Pengkajian)
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C. Riwayat penyakit dahulu
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D.Pengetahuan tetang Penyakit / Perawatan
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2. Buang air Kecil
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G. Pola Peran dan hubungan ( Komonikasi , hubungan)
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E. Makan dan Minum,toileting ,berpakaian, mobilitas
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F. Pola nutrisi /metabolic
 Intake makanan
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 Intake cairan
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F.Pola Eliminasi
1. Buang Air Besar
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K. Pola seksualitas dan reproduksi
(fertilitas ,libido,menstruasi,kontraepsi,dll)
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L.Sistim Nilai dan Kpercayaan ( Pandangan Klien tentang
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H. Pola istirahat dan tidur( lama tidur, gangguan tidur, M. Pemeriksaan Fisik
Perasaan saat bangun tidur) 1. Kepala
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I. Pola Persepsi (Penglihatan, Pendengaran,Pengecapan 2. Leher
Sensasi.) ………………………………………………………………………………………..
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J. Pola Persepsi Diri (Pandangan klien tentang sakitnya, 3. Thorak
Kecemasan, Konsep diri) ……………………………………………………………………………….…………
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4. Abdomen
Tekanan darah
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TD : ……………….. mmhg
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Suhu. : ………………… ˚ C
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……………………………………………………………………………………… Nadi : ……………….. x/ menit
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5. Ektremitas
Pernafasan : ……………… x/ menit
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…………………………………………………………………………………….. Berat Badan : ……………….. kg
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Tinggi Badan : ……………….. cm
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 Program terapi
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Pemeriksaan Penunjang dan Labor
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Analisa Data
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Diagnosa Keperawatan

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 RENCANA TINDAKAN KEPERAWATAN TINDAKAN KEPERAWATAN

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EVALUASI KEPERAWATAN (SOAP)

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Mengetahui : Perawat yang melakukan
Kepala Ruangan

NS. ANDRIYANI S.Kep