Nama mahasiswa : ........................................ Tgl/jam MRS : ........................................

Tgl/jam pengkajian : ........................................ No. RM : ........................................

Diagnosa medis : ........................................ Ruangan/kelas : ........................................
........................................ No.kamar : ........................................

I. IDENTITAS
1. Nama : .....................................................................................................................
2. Umur : .....................................................................................................................
3. Jenis kelamin : .....................................................................................................................
4. Status : .....................................................................................................................
5. Agama : .....................................................................................................................
6. Suku/bangsa : .....................................................................................................................
7. Bahasa : .....................................................................................................................
8. Pendidikan : .....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat dan no. telp : .....................................................................................................................
11. Penanggung jawab : .....................................................................................................................

II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN

1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Lamanya keluhan
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4. Faktor yang Memperberat
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5. Upaya yang Dilakukan Untuk Mengatasi Keluhan
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6. Riwayat penyakit dahulu :
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7. Persepsi klien tentang status kesehatan dan kesejahteraan
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 8. Riwayat kesehatan keluarga :
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9. Susunan keluarga (genogram) :

10. Riwayat alergi :

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Diagnosa keperawatan : ..................................................................................................................

III. POLA NUTRISI DAN METABOLIK

1. Pola makan
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Porsi : ......................... Porsi : ..................................
Pantangan : ......................... Diit khusus : ..................................
Makanan disukai : .........................
Nafsu makan di RS : ( ) normal ( ) bertambah ( ) berkurang
( ) mual ( ) muntah, .............. cc ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) ya
Gigi palsu : ( ) tidak ( ) ya
NG tube : ( ) tidak ( ) ya

2. Pola minum
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Jumlah : ......................... Jumlah : ..................................
Pantangan : .........................
Minuman disukai : .........................

Diagnosa keperawatan : ..................................................................................................................

IV. POLA ELIMINASI

1. Buang air besar
Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya
 2. Buang air kecil
Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Jumlah : .................................. Jumlah : ..................................
Warna : .................................. Warna : ..................................
Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria
( ) retensi ( ) inkontinen
Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari

Diagnosa keperawatan : ..................................................................................................................

V. POLA AKTIVITAS DAN LATIHAN

1. Kemampuan perawatan diri
SMRS MRS
Aktivitas
0 1 2 3 4 0 1 2 3 4
Mandi
Berpakaian/berdandan
Eliminasi/toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah

Skor 0 = mandiri 3 = dibantu orang lain & alat

1 = alat bantu 4 = tergantung/tidak mampu
2 = dibantu orang lain

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat

( ) pispot disamping tempat tidur ( ) kursi roda

2. Kebersihan diri
Di rumah Di rumah sakit
Mandi : ........................ /hr
¿ Mandi : ........................ ¿ /hr
Gosok gigi : ........................ ¿ /hr Gosok gigi : ........................ ¿ /hr
Keramas : .................... /mgg
¿ Keramas : .................... ¿ /mgg
Potong kuku : .................... ¿ /mgg Potong kuku : .................... ¿ /mgg
3. Aktivitas sehari-hari
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4. Rekreasi
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5. Olahraga : ( ) tidak ( ) ya
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Diagnosa keperawatan : ..................................................................................................................

VI. POLA ISTIRAHAT DAN TIDUR

Di rumah Di rumah sakit
Waktu tidur : Siang ..............-............... Waktu tidur : Siang ..............-...............
Malam ............-............... Malam ............-...............
Jumlah jam tidur : ....................................... Jumlah jam tidur : .......................................
Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk
( ) insomnia ( ) Lainnya, ..............................................................................
 Diagnosa keperawatan : ..................................................................................................................

VII. POLA KOGNITIF DAN PERSEPTUAL

Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas
Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ....................................
Kemampuan membaca : ( ) bisa ( ) tidak
Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik
Sebab, ...................................................................................................
Kemampuan interaksi : ( ) sesuai ( ) tidak,....................................................................

Vertigo : ( ) tidak ( ) ya
Nyeri : ( ) tidak ( ) ya

Bila ya, P : .........................................................................................................................................

Q : .........................................................................................................................................
R : .........................................................................................................................................
S : .........................................................................................................................................
T : .........................................................................................................................................

Diagnosa keperawatan : ..................................................................................................................

VIII. POLA PERSEPSI DIRI / KONSEP DIRI

1. Body image/gambaran diri
( ) cacat fisik ( ) pernah operasi
( ) perubahan ukuran fisik ( ) proses patologi penyakit
( ) fungsi alat tubuh terganggu ( ) kegagalan fungsi tubuh
( ) keluhan karena kondisi tubuh ( ) gangguan struktur tubuh
( ) transplantasi alat tubuh ( ) menolak berkaca
( ) prosedur pengobatan yang mengubah fungsi alat tubuh
( ) perubahan fisiologis tumbuh kembang
Jelaskan : .......................................................................................................................................

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Diagnosa keperawatan : ...............................................................................................................
2. Role/peran
( ) overload peran ( ) perubahan peran ( ) transisi peran karena
( ) konflik peran ( ) keraguan peran sakit
Jelaskan : .......................................................................................................................................

........................................................................................................................................
Diagnosa keperawatan : ...............................................................................................................
3. Identity/identitas diri
( ) kurang percaya diri ( ) merasa kurang memiliki potensi
( ) merasa terkekang ( ) kurang mampu menentukan pilihan
( ) tidak mampu menerima perubahan ( ) menolak menjadi tua
Jelaskan : .......................................................................................................................................

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Diagnosa keperawatan : ...............................................................................................................
4. Self esteem/harga diri
( ) mengkritik diri sendiri dan orang ( ) rasa bersalah
lain ( ) menyangkal kepuasan diri
( ) merasa jadi orang penting ( ) polarisasi pandangan hidup
( ) menunda tugas ( ) mencemooh diri
( ) merusak diri ( ) mengecilkan diri
( ) menyangkal kemampuan pribadi ( ) keluhan fisik
 ( ) menyalahgunakan zat
Jelaskan : ......................................................................................................................................

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Diagnosa keperawatan : ...............................................................................................................
5. Self ideal/ideal diri
( ) masa depan suram ( ) tidak ingin berusaha
( ) terserah pada nasib ( ) tidak memiliki cita-cita
( ) merasa tidak memiliki kemampuan ( ) merasa tidak berdaya
( ) tidak memiliki harapan ( ) enggan membicarakan masa depan
Jelaskan : .......................................................................................................................................

...........................................................................................................................................
Diagnosa keperawatan : ..................................................................................................................

IX. POLA PERAN DAN HUBUNGAN

Pekerjaan : ..........................................................................................................
Kualitas bekerja : ..........................................................................................................
Hubungan dengan orang lain :
Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya,......................................................................................
Masalah keluarga mengenai perawatan di RS : ...................................................................................

Diagnosa keperawatan : ..................................................................................................................

X. POLA SEKSUALITAS / REPRODUKSI

Menstruasi terakhir : .....................................................................................................................
Masalah menstruasi : .....................................................................................................................
Pap smear terakhir : .....................................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit : ...............................................................

Diagnosa keperawatan : ..................................................................................................................

XI. POLA KOPING / TOLERANSI STRESS

1. Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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2. Kehilangan perubahan yang terjadi sebelumnya
a. Tahap Denial/Penolakan
( ) penolakan terhadap situasi ( ) merasa tertekan
( ) tidak percaya pada orang lain ( ) wawasan sempit
Jelaskan : .................................................................................................................................

..................................................................................................................................
Diagnosa keperawatan : .........................................................................................................
b. Tahap Anger/Marah
( ) marah pada diri sendiri ( ) meningkatnya kesadaran klien
( ) marah pada orang lain pada realita
Jelaskan : .................................................................................................................................
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Diagnosa keperawatan : .........................................................................................................
3. Kemampuan adaptasi
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Diagnosa keperawatan : ..................................................................................................................

XII. POLA NILAI / KEPERCAYAAN

Agama : ................................................................................................
Pelaksanaan ibadah : ................................................................................................
Pantangan agama : ( ) tidak ( ) ya, ................................................................
Meminta kunjungan rohaniawan : ( ) tidak ( ) ya

Diagnosa keperawatan : ..................................................................................................................

XIII. PENGKAJIAN PERSISTEM (Review of System)

1. Tanda-Tanda Vital
a. Suhu : ................... °C lokasi : ......................
b. Nadi : ................... ¿ /menit irama : ...................... pulsasi : ......................
c. Tekanan darah : ................... mmHg lokasi : ......................
d. Frekuensi nafas : ................... ¿ /menit irama : ......................
e. Tinggi badan : ................... cm
f. Berat badan : SMRS ................... kg MRS .................... kg

2. Sistem Pernafasan (Breath)

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Diagnosa keperawatan : ..................................................................................................................

3. Sistem Kardiovaskuler (Blood)

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Diagnosa keperawatan : ..................................................................................................................

4. Sistem Persarafan (Brain)

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Diagnosa keperawatan : ..................................................................................................................

5. Sistem Perkemihan (Bladder)

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Diagnosa keperawatan : ..................................................................................................................

6. Sistem Pencernaan (Bowel)

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Diagnosa keperawatan : ..................................................................................................................

7. Sistem Muskuloskeletal (Bone)

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Diagnosa keperawatan : ..................................................................................................................

8. Sistem Integumen
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Diagnosa keperawatan : ..................................................................................................................

9. Sistem Penginderaan
Mata
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Hidung
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Telinga
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Diagnosa keperawatan : ..................................................................................................................

10. Sistem Reproduksi Dan Genetalia

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Diagnosa keperawatan : ..................................................................................................................

XIV. PEMERIKSAAN PENUNJANG

1. Laboratorium
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2. Photo
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3. Lain-lain
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XV. TERAPI
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XVI. Pathway

...................., .....................
Mahasiswa

(...............................)
 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

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

No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

 PRIORITAS MASALAH

Nama klien : .............................................. Ruangan/kamar : ..............................................

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

Tanggal Paraf
No. Diagnosa keperawatan
Ditemukan Teratasi (Nama perawat)
 RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

Waktu Waktu Catatan Perkembangan

No. Tindakan TT TT
Tgl/jam Tgl/jam (SOAP)