format pengkajian dm ns.margaretha bangkut sem iv
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FORMAT PENGKAJIAN KEPERAWATAN
KEPERAWATAN MEDIAKAL BEDAH
FAKULTAS KEPERAWATAN UNIVERSITAS SARI PUTRA INDONESIA
TOMOHON
UNIT : TGL PENGKAJIAN :
RUANG/KAMAR : WAKTU PENGKAJIAN :
TGL MASUK RS : Auto Anamnese :
AlloAnamnese :
I. IDENTITAS
A. KLIEN :
NAMA INITIAL :
TEMPAT/TGL LAHIR(UMUR :
JENIS KELAMIN : LAKI!LAKI PEREMPUAN
STATUS PERKAWINAN :
JUMLAH ANAK :
AGAMA/SUKU :
WARGA NEGARA : IND"NESIA ASING#AHASA $ANG DIGUNAKAN : IND"NESIA
DAERAH%%%%%%%%%%%%%%%.
ASING%%%%%%%%%%%%%%%%..
PENDIDIKAN :
PEKERJAAN :
ALAMAT RUMAH :#. PENANGGUNG JAWA#
NAMA :
ALAMAT :
HU#UNGAN DENGAN KLIEN :
II. DATA MEDIK :
A. DIKIRIM "LEH : UGD D"KTER PRAKTEK #. DIAGN"SA MEDIK :
SAAT MASUK :
SAAT PENGKAJIAN :
III. KEADAAN UMUM
A. KEADAAN SAKIT :
1
NAMA MAHASISWA YANG MENGKAJI: NIM:
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#. ALASAN :
&. KELUHAN UTAMA :
D. RIWA$AT KELUHAN UTAMA :
E. KELUHAN $ANG MEN$ERTAI :
'. TANDA!TANDA ITAL :). KEASADARAN
Kual*tat*+ : &om,os ment*s Somnolens &oma
A,at*s So,o-oomateus
Kuant*tat*+ :
Sala &oma Glas0o1:
• Res,on moto-* :
• Res,on 2*a-a :
• Res,on mem2ua mata :
Kes*m,ulan :
'la,*n0 T-emo-/aste-*s*s : Pos*t*+ Ne0at*3e
4. TEKANAN DARAH :
MAP :%%%%%%%%%%%%%%%mmH0
Kes*m,ulan :
5. SUHU : o-al A6*lla- Retal
7. NADI :
8. PERNAPASAN :
I-ama : Te-atu- Kusmaul &9enes!stoes
Jen*s : Da;a Pe-ut
G. PENGUKURAN). L*n0a- len0an atas :%%%%%%%%%m
4. L*,at ul*t t-*e,s :%%%%%%%%%m
5. T*n00* 2a;an :%%%%%%%%%m #e-at 2a;an :%%%%%.0
I.M.T (*n;e6 massa tu2u9 :%%%%%%%%%0/ m2
Kes*m,ulan :%%%%%%%%%%%%%%%%%%%%%%%%%...
&atatan :%%%%%%%%%%%%%%%%%%%%%%%%%...
H. GEN"GRAM
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I. PENGKAJIAN P"LA KESEHATAN ()) G"RD"N
A. KAJIAN PERSEPSI KESEHATAN PEMELIHARAAN KESEHATAN
R*1aat ,ena*t an0 ,e-na9 ;*alam*:Sa*t 2e-at< ;*-a1at
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
2. Kea;aanse=asa*t:
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
2. Data #bjet!"
a. "2se-3as*
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b. Peme-*saan+*s*
• Kea;aan-am2ut%%%%%%%%%%%%%%%%%%%%%%%%%%%
• H*;-as*ul*t%%%%%%%%%%%%%%%%%%%%%%%%%%%%...
• Pal,e2-ae%%%%%%%%%%%%%
on=un0t*3a%%%%%%%%%%%%%%%%...
• Sle-a%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.
• H*;un0%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%...
• Ron00amulut%%%%%%%%%%%Gus*%%%%%%%%%%%%%%%.
• G*0* 0el*0*%%%%%%%%%%%%...G*0* ,alsu%%%%%%%%%%%%..
• Kemam,uanmen0una9e-as%%%%%%%%%%%%%%%%%%%%%.
• L*;a9%%%%%%%%%%%%%%%Tons*l%%%%%%%%%%%%%%
• P9a-*n0%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%...
• Kelen=a-0eta92en*n0le9e-%%%%%%%%%%%%%%%%%%%%%%...
• Kelen=a-,a-ot*s%%%%%%%%%%%.Kelen=a-t*-o*;%%%%%%%%%%.
• A2;omen
Ins,es* : #entu%%%%%%%%%%%%%%%%%%%%%%
#aan0an 3ena%%%%%%%%%%%%%%%%%%...
#en=olan 3ena%%%%%%%%%%%%%%%%%%%
Ausultas* : Pe-*stalt*%%%%6/men*t
Pal,as* : Tan;ane-*umum%%%%%%%%%%%%%%%%%.
Massa%%%%%%%%%%%%%%%%%%%%%%
H*;-as*ul*t%%%%%%%%%%%%%%%%%%%...
Ne-*tean: R. E,*0ast-*a T*t* M. #u-ne
R. Su,-a,u2*a R. Ill*aaHe,a-%%%%%%%%%%%%%%%%%%%%%%.
L*en%%%%%%%%%%%%%%%%%%%%%%%
Pe-us* : %%%%%%%%%%%%%%%%%%%%%%%%...
As*tes : Ne0at*3e
Pos*t*3e< l*n0a-,e-ut%%%%/%%%../%%%%.m
• Kelen=a-l*m+e *n0u*nal%%%%%%%%%%%%%%%%%%%%%%%%%
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• Kul*t :
o S,*;e- nae3* : Ne0at*+ Pos*t*+
o U-em* +-ost : Ne0at*+ Pos*t*+
o E;ema : Ne0at*+ Pos*t*+
o Ite-* : Ne0at*+ Pos*t*+
o
Tan;a-a;an0%%%%%%%%%%%%%%%%%%%%%%%%%..• Les*%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..
$. Pe%e&!'aa(D!a)(#'t!
• La2o-ato-*um:
• La*n!la*n
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*. Te&a+!,
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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-. KAJIAN POLA ELIMINASI1. Data Subjet!"
a. Kea*aa( 'ebeu% 'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b. Kea*aa( 'eja 'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%2. Data Objet!"
a. Ob'e&/a'!
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b. Pe%e&!'a( "!'!
• Pe-*stalt* usus:%%%%%.6/men*t
• Pal,as*su,-a,u2*a :an;un0em*9 ,enu9 Koson0
• Ne-*etu0*n=al :*-*
• Mulutu-et-a : anan
• Anus :
Pe-a;an0an :
'*ssu-a :
Hemo--9o*; :
P-ola,ses -et* :
'*stula an* :
Massa tumo- :
$. Pe%e&!'aa(*!a)(#'t!
• La2o-ato-*um
• La*n!la*n
*. Te&a+!,
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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D. KAJIAN POLA AKTIFITAS DAN LATIHAN
1. Data Subjet!"
a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
2. Data Objet!" a. Ob'e&/a'!
• At*+*tas9a-*an
Maan :
Man;* :
#e-,aa*an :
Ke-a,*9an :
#uan0 a*- 2esa- :
#uan0 a*- e*l :
Mo2*l*tas ;* tem,att*;u- :
Am2ulas* : man;*-*/ton0at/u-s*-o;a/tem,att*;u-
• Postu-tu2u9 : %%%%%%%%%%%%%%%%..• Gaa =alan : %%%%%%%%%%%%%%%%..
• An00ota0e-a an0 aat: %%%%%%%%%%%%%%%%..
• '*sas* : %%%%%%%%%%%%%%%%..
• T-a9eostom : %%%%%%%%%%%%%%%%..
b. Pe%e&!'a("!'!
• JP%%%%%%%.mH4"%%%%%%%%%%%%%%%%%%%
• Pe-us*,em2ulu,e-*+e- uu%%%%%%%%%%%%%%%%%%%
• T9o-as;an,e-na,asan
#entuto-a6 :
St-*;o- : Ne0at*+ Pos*t*+
Ds,noe;>E++o-t : Ne0at*+ Pos*t*+ Sanos*s : Ne0at*+ Pos*t*+
Pal,as* : 3oal +e-m*tus
Pe-us* : Sono- Re;u, Pea
#atas ,a-u9e,a- : %%%%%%%%%%%%...
Kes*m,ulan : %%%%%%%%%%%%...
Ausultas* :Sua-ana,as : %%%%%%%%%%%%...
Sua-aua,an : %%%%%%%%%%%%...
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0 :mandiri
1 :bantuandn!ana"at
2 :bantuan #ran!
3 :bantuan #ran!
dana"at
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Sua-atam2a9an : %%%%%%%%%%%%...
• Jantun0
Ins,es* : Itus o-;*s
Kl*enmenn0unaanalat,au=an0tun0 Ne0at*+ Pos*t*+
Pal,as* : Itus o-;*s
Pe-us* : #atas atas=antun0 : %%%%%%%%%%%......
#atas anan=antun0 :
%%%%%%%%%%%%%..
#atas *-*=antun0 :
%%%%%%%%%%%%%
Ausultas* : #un*=antun0 II A :
#un*=antun0 II P :
#un*=antun0 I T :
#un*=antun0 I M :
#un*=antun0 III I-amaGallo, : Ne0at*+
Pos*t*+ Mu-mu- : Ne0at*+ Pos*t*+< Tem,at :
%%%%.
G-a;e :
%%%%.
HR :%%%%%%%..6/men*t
#un* ao-ta : Ne0at*+ Pos*t*+
A-te-*-enal*s : Ne0at*+ Pos*t*+
Mat*A-te-*+emo-al*s : Ne0at*+ Pos*t*+
• Len0an;antun0a*
At-o+*otot : Ne0at*+ Pos*t*+
Rentan00e-a :
%%%%%%%%%%%%%%%%%%%%%%.
Mat*sen;* :
%%%%%%%%%%%%%%%%%%%%%%.
Kausen;* :
%%%%%%%%%%%%%%%%%%%%%%.
U=*euatanotot : K*-* :
Kanan :
Re+le6 +*s*olo0* :
%%%%%%%%%%%%%%%%%%%%%%.
Re+le6 ,atolo0* : #a2*ns* *-* : Ne0at*+ Pos*t*+
#a2*ns* anan : Ne0at*+ Pos*t*+
&lu22*n0 =a-*!=a-* : Ne0at*+ Pos*t*+
a-*sestun0a* : Ne0at*+ Pos*t*+
• &olumna3e-te2-al*s
Ins,es* :
%%%%%%%%%%%%%%%%%%%%%%.
&
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Pal,as* :Ne-*tean Ne0at*+ Pos*t*+
N III!I!I :
%%%%%%%%%%%%%%%%%%%%%%.
N III test -om2e-0 : Ne0at*+ Pos*t*+
N ?I :
%%%%%%%%%%%%%%%%%%%%%%.
Kauu;u :
%%%%%%%%%%%%%%%%%%%%%%.
$. Pe%e&!'aa(*!a)(#'t!
Lab#&at#&!u%
La!(0a!(
*. Te&a+!,
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%
E. KAJIAN POLA TIDUR DAN ISTIRAHAT
1. Data Subjet!"
a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
2. Data Objet!"
a. Ob'e&/a'!
• Es,-es*1a=a9men0antu : Ne0at*+ Pos*t*+
• #anamen0ua, : Ne0at*+ Pos*t*+
• Pal,e2-ae *n+e-*o- 2e-1a-na0ela, : Ne0at*+ Pos*t*+
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b. Te&a+!,
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F. KAJIAN POLA PERSEPSI KOGNITIF
1. Data Subjet!"
a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%
b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%
2. Data Objet!"
a. Ob'e&/a'!
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%
b. Pe%e&!'a("!'!
• Pen0l*9atan
&o-nea :
%%%%%%%%%%%%%%%%%%%%%%%
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*sus :
%%%%%%%%%%%%%%%%%%%%%%%
Pu,*l :
%%%%%%%%%%%%%%%%%%%%%%%
Lensamata :
%%%%%%%%%%%%%%%%%%%%%%% Teanan Int-a "ule- :
%%%%%%%%%%%%%%%%%%%%%%%
• Pen;en0a-an
P*na :
%%%%%%%%%%%%%%%%%%%%%%%
&anal*s :
%%%%%%%%%%%%%%%%%%%%%%%
Mem2-ane Tm,an* :
%%%%%%%%%%%%%%%%%%%%%%%
Tes,en;en0a-an :
%%%%%%%%%%%%%%%%%%%%%%%• Pen0enalan -asa ,os*s*,a;a0e-aanlen0an;antun0a*
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%...
• N I :
%%%%%%%%%%%%%%%%%%%%%%%
• N II :
%%%%%%%%%%%%%%%%%%%%%%%
• N Senso-* :
%%%%%%%%%%%%%%%%%%%%%%%
• N III Pen;en0a-an :
%%%%%%%%%%%%%%%%%%%%%%%
• TesRom2e0 :
%%%%%%%%%%%%%%%%%%%%%%%
$. Pe%e&!'aa(*!a)(#'t!
Lab#&at#&!u%
La!(0a!(
*. Te&a+!,
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%
G. KAJIAN POLA PERSEPSI DAN KONSEP DIRI
1. Data Subjet!"
a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%
b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%
2. Data Objet!"
a. Ob'e&/a'!
• Kontamata :
%%%%%%%%%%%%%%%%%%%%%%...
• Rentan0,e-9at*an :
%%%%%%%%%%%%%%%%%%%%%%...
• Sua-a;ana-a2*a-a :
%%%%%%%%%%%%%%%%%%%%%%...
• Postu-tu2u9 :
%%%%%%%%%%%%%%%%%%%%%%...
b. Pe%e&!'a("!'!
• Kela*nan2a1aan an0 nata :
%%%%%%%%%%%%%%%%%%%%%%...
•
A2;omen: #entu :%%%%%%%%%%%%%%%%%%%%%%...
#aan0an 3ena :
%%%%%%%%%%%%%%%%%%%%%%...
#aan0anmassa :
%%%%%%%%%%%%%%%%%%%%%%...
• Kul*t : Les*ul*t :
• Pen00unaan,-otesa : H*;un0 Pau;a-a
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Len0an Tun0a*
H. KAJIAN POLA PERAN DAN HUBUNGAN DENGAN SESAMA
1. Data Subjet!"
a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%
b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%
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I. KAJIAN POLA REPRODUKSI0SEKSUALITAS
1. Data Subjet!" a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%
b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%
2. Data Objet!"
a. Ob'e&/a'!
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
b. Pe%e&!'a("!'!
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%
$. Pe%e&!'aa(*!a)(#'t!
Lab#&at#&!u%
La!(0a!(
*. Te&a+!,
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%
J. KAJIAN MEKANISME KOPING DAN TOLERANSI TERHADAP STRES
1. Data Subjet!"
a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%
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b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%
2. Data Objet!"
a. Ob'e&/a'!
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%
b. Pe%e&!'a("!'!
• Teanan;a-a9 : #e-2a-*n0 : %%%%%%.mmH0
Du;u : %%%%%%.mmH0
#e-;*-* : %%%%%%.mmH0
Kes*m,ulanH*,otens*"-tostat* : Ne0at*+ Pos*t*+
• HR : %%%%%%%%%%%%%.6/men*t
• Kul*t : Ke-*n0at;*n0*n :
%%%%%%%%%%%%%%%%%%%%.
#asa9 :
%%%%%%%%%%%%%%%%%%%%.
$. Te&a+!,
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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K. KAJIAN POLA NILAI KEPER-AAAN
1. Data Subjet!"
a. Kea*aa('ebeu%'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%%%%%%%
b. Kea*aa('eja'a!t
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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%%%%%%%%
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%%%%%%%%
2. Data Objet!" a. Ob'e&/a'!
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
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Namadan(anda(an!an )an!Mn!*a+i
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FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA NDONESIA TOMOHON
KLASIFIKASI DATA
NO DATA SUBJEKTIF DATA OBJEKTIF
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FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA NDONESIA TOMOHON
PATOFLOWPENIMPANGAN KDM
1&
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FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA NDONESIA TOMOHON
ANALISA DATA
NO DATA ETHIOLOGI DATA OBJEKTIF
1'
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FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA NDONESIA TOMOHON
DIAGNOSA KEPERAWATAN
NAMA ,RUMAH SAKIT ,
RUANGKAMAR ,
NO DATA ETHIOLOGI DATA OBJEKTIF
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FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA NDONESIA TOMOHON
INTERVENSI (NursingCare Plan)
DI UNIT RAWAT INAP RS,3333333333
NAMA PASIEN , 333333333 RUANGAN,3333.. NO RM ,
33333
NO DIAGNOSA
KEPERAWATAN
TUJUAN INTERVENSI RASIONAL
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FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA NDONESIA TOMOHON
ASUHAN KEPEAWATAN
DI UNIT RAWAT INAP RS,3333333333
NAMA PASIEN , 333333333 RUANGAN,3333.. NO RM ,
33333
NO DIAGNOSA
KEPERAWATAN
IMPLEMENTASI EVALUASI NAMA
JELAS
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