FORMAT PENGKAJIAN

APLIKASI TEORI MODEL SELF CARE OREM

STIKES HANG TUAH SURABAYA

A. PENGKAJIAN
1. Universal Self Care
a. Kebutuhan oksigen
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b. Kebutuhan Cairan
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c. Kebutuhan Nutrisi
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d. Kebutuhan Eliminasi
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e. Interaksi Sosial
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f. Istirahat dan Tidur
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g. Konsep Diri
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2. Development Self Care

a. Identitas Anggota kelompok
1) Usia : .......... tahun
2) Jenis kelamin : L / P
3) Pendidikan : .................................................................................................................
4) Agama : .................................................................................................................
5) Pekerjaaan : .................................................................................................................
6) Suku : .................................................................................................................
b. Penyakit Keturunan
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c. Persepsi terhadap penyakitnya
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d. Pengetahuan Terhadap Penyakit
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3. Health Deviation
a. Tindakan preventif yang dilakukan untuk mengatasi masalah
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b. Halangan untuk melakukan tindakan preventif
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B. DIAGNOSA KEPERAWATAN
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 RENCANA KEPERAWATAN
No dx Penuh/wholly Sebagian/partial Supportif Edukatif
 IMPLEMENTASI DAN EVALUASI
No. Dx Implementasi Evaluasi