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Nama : RM :
Umur : Jenis kelamin :
Agama : Pendidikan :
terakhir
Pekerjaan :
Alamat :
Diagnosa :
Medis
B. Identitas Penanggungjawab
Nama : Umur :
Hubungan :
No Tlp :
Alamat :
C. Riwayat Kesehatan
Keluhan utama
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Pengkajian Keperawatan Model Adaptasi Roy 2018
Herbal:
Allergi
Obat :Tidak/ Ada : sebutkan............
Makanan : Tidak/ Ada : sebutkan............
Lainnya : Tidak/ Ada : sebutkan............
Riwayat operasi/Kemotherapi/Radioterapi
__________________________________ tahun _________________
__________________________________ tahun _________________
Ct scan renal:
Biopsy renal:
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Rotgent thoraks:
Dopler cimino:
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II. ADAPTASI
A. FISIOLOGIS
1. OKSIGENASI
Data Subjektif:
Data Objetif:
a. Fisik
b. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
2. SIRKULASI
Data Subjektif:
Data Objetif:
a. Fisik
b. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
3. NUTRISI
Data Subjetif:
Data Objektif:
a. Antropometri
TB: cm, BB: Kg, IMT:
Kesimpulan:
@Napsan Junaidi/1506707341
Pengkajian Keperawatan Model Adaptasi Roy 2018
b. Biomedic
c. Clinical
d. Diet
f. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
4. ELIMINASI
Data Subjektif:
Data Objektif:
a. Fisik
BAK:
a. Pola eliminasi urin:
- Frekuensi berkemih: anuri, oliguri, poliuria:
- Inkontinensia urin:
- Nokturia:
- Disuria:
b. Karakteristik urin (warna, bau, jumlah, hematuria, atau nanah)
c. Kesulitan berkemih:
BAB:
b. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
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Pengkajian Keperawatan Model Adaptasi Roy 2018
Stimulus Residual:
Kemampuan:
Istirahat dan tidur:
Bhartel Indexs:
b. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
b. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
7. SENSORI
a. Fisik
Nyeri P:
Q:
R:
S:
T:
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Pengkajian Keperawatan Model Adaptasi Roy 2018
b. Lainnya
c. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
Osmolaritas:
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Pengkajian Keperawatan Model Adaptasi Roy 2018
b. Pengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
9. FUNGSI NEUROLOGI
a. Fisik
Lainnya
Status Mental
Tk. Kesadaran Compos mentis /apatis / delirium / letargi / sopor /
soporacomatous
Memory : Panjang Pendek
Perhatian : Dapat mengulang Tidak dapat mengulang
Bahasa : Baik Tidak
Kognisi : Baik Tidak
Orientasi : Orang Tempat Waktu
Saraf sensori Nyeri tusuk Suhu Sentuhan
Lainnya: ______________
Saraf koordinasi Ya Tidak
(cerebral)
GCS : E M V =
PengkajPengkajian Stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
10. ENDOKRIN
a. Fisik
Kalenjar tiroid Pembesaran: Ya Tidak
Tremor : Ya Tidak
b. P
Pankreas Trias DM : Ya Tidak
e
Adrenal Tanda Syndrom cushing Ya Tidak
n
Pengkajian lain
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Pengkajian Keperawatan Model Adaptasi Roy 2018
c. Pengkajian stimulus
Stimulus Fokal:
Stimulus Kontekstual:
Stimulus Residual:
3. KONSEP DIRI
a. Physical Self
b. Personal Self
Stimulus Fokal :
Stimulus Kontekstual :
Stimulus Residual :
4. Fungsi Peran
Stimulus Fokal :
Stimulus Kontekstual :
Stimulus Residual :
5. Interdependen
Stimulus Fokal :
Stimulus Kontekstual :
Stimulus Residual :
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Pengkajian Keperawatan Model Adaptasi Roy 2018
Focus diri
Identitas diri
Pengambilan
peran
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Pengkajian Keperawatan Model Adaptasi Roy 2018
Pengkajian Stimulus
Pola Pengkajian Perilaku
Stimulus Fokal Stimulus Kontekstual Stimulus Residual
Integrasi peran
3. Adaptasi Interdependensi
Pengkajian Stimulus
Pola Pengkajian Perilaku
Stimulus Fokal Stimulus Kontekstual Stimulus Residual
Affectional
adequacy
Sumber daya
yang adekuat
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Pengkajian Keperawatan Model Adaptasi Roy 2018
4. Diagnosis Keperawatan
1. ..............................................................................................................................................
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2. ..............................................................................................................................................
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3. ..............................................................................................................................................
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4. ..............................................................................................................................................
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5. ..............................................................................................................................................
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Pengkajian Keperawatan Model Adaptasi Roy 2018
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Pengkajian Keperawatan Model Adaptasi Roy 2018
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Pengkajian Keperawatan Model Adaptasi Roy 2018
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Pengkajian Keperawatan Model Adaptasi Roy 2018
6. IMPLEMENTASI
Dx : .......................................................................................... Dx : S:
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Hari: .......................................................................................... Hari: ..........................................................................................
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Tgl .......................................................................................... Tgl ..........................................................................................
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Jam: .......................................................................................... Jam: ..........................................................................................
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Dx : .......................................................................................... Dx : S:
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Hari: .......................................................................................... Hari: ..........................................................................................
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Tgl .......................................................................................... Tgl ..........................................................................................
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Jam: .......................................................................................... Jam: ..........................................................................................
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Pengkajian Keperawatan Model Adaptasi Roy 2018
7. EVALUASI
Hari: S: Hari: S:
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Tgl .......................................................................................... Tgl ..........................................................................................
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Jam: .......................................................................................... Jam: ..........................................................................................
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O: O:
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A A
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P: P:
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@Napsan Junaidi/1506707341
Pengkajian Keperawatan Model Adaptasi Roy 2018
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