FORMAT PENGKAJIAN

APLIKASI TEORI MODEL KONSEP ADAPTASI ROY

STIKES HANG TUAH SURABAYA

A. PENGKAJIAN1. Identitas Klien

a. Nama : ........................................................................................................................b. Jenis kelamin : L / Pc. Umur : .......... tahund. Agama: ........................................................................................................................e. Pendidikan : ........................................................................................................................f. Pekerjaan : ........................................................................................................................g. Suku : ........................................................................................................................h. Alamat: ........................................................................................................................

2. Pengkajian Tahap pertamaa. Fisiologi

1) Oksigenasi dan ventilasi..........................................................................................................................................................................................................................................................................................

2) Nutrisi..........................................................................................................................................................................................................................................................................................

3) Eliminasi..........................................................................................................................................................................................................................................................................................

4) Aktivitas..........................................................................................................................................................................................................................................................................................

5) Istirahat..........................................................................................................................................................................................................................................................................................

6) Sense..........................................................................................................................................................................................................................................................................................

7) Cairan, elektrolit, dan keseimbangan asam basa..........................................................................................................................................................................................................................................................................................

8) Fungsi neurologis..........................................................................................................................................................................................................................................................................................

9) Endokrin ..........................................................................................................................................................................................................................................................................................

b. Konsep diri.........................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. Fungsi peran.........................................................................................................................................................................................................................................................................................................................................................................................................................................................

d. Ketergantungan.........................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Pengkajian Tahap KeduaMode fisiologi

Perilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

Konsep diriPerilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

Fungsi PeranPerilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

InterdependensiPerilaku klien Stimulus fokal Stimulus kontekstual Stimulus residual

B. DIAGNOSA KEPERAWATAN......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

RENCANA DAN TINDAKAN KEPERAWATANNo. Dx Tujuan Intervensi

IMPLEMENTASI DAN EVALUASINo. Dx Implementasi Evaluasi