FORMAT ASUHAN KEPERAWATAN
A. PENGKAJIAN
1. Pengumpulan
Data
a.
Biodata
1)
Nama : .....................................
2)
No Register : .....................................
3)
Jenis Kelamin : .....................................
4)
Umur : .....................................
5)
Status Perkawinan
: ....................................
6)
Pekerjaan : .....................................
7)
Agama : .....................................
8)
Pendidikan Terakhir : .....................................
9)
Alamat : .....................................
10) Tanggal
MRS : .....................................
11) Tanggal
pengkajian : .....................................
12) Sumber informasi : .....................................
13) Ruangan : .....................................
b. Diagnosa
Medis : .....................................
c.
Keluhan Utama
Saat MRS
...........................................................................................................................................
...........................................................................................................................................
Saat
Pengkajian
...........................................................................................................................................
d.
Riwayat Penyakit Sekarang
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
e.
Riwayat Kesehatan/Penyakit Yang Lalu
...........................................................................................................................................
........................................................................................................................................................................................................................................................................................
f.
Riwayat Kesehatan Keluarga
............................................................................................................................................
……………………………………………………………………………………………
g.
Genogram
h.
Pola Aktivitas Sehari-hari
1) Makan
dan minum
Di RM ..........................................................................................................................
..………………………………………………………………………………
Di RS ..........................................................................................................................
.………………………………….……………………………………………
2) Pola
eliminasi
Di RM ..........................................................................................................................
..………………………………………………………………………………
Di RS ..........................................................................................................................
..………………………………………………………………………………
3) Pola
istirahat dan tidur
Di RM ..........................................................................................................................
…..……………………………………………………………………………
Di RS ..........................................................................................................................
..………………………………………………………………………………
4) Kebersihan
diri
Di RM ..........................................................................................................................
…..……………………………………………………………………………
Di RS ..........................................................................................................................
..………………………………………………………………………………
i.
Riwayat Psikologis
........................................................................................................................................................................................................................................................................................
j.
Pemeriksaan Fisik
1) Keadaan
umum
…………………………………………………………………………………….....
………………………………………………………….............................................
………………………………………………………………………………………...
2) Tanda
vital
Tekanan
Darah : ………./...……mmHg Nadi :
………...x/menit
Pernafasan
: …………x/menit Suhu
: ……….0C
3) Pemeriksaan
Kepala
Inspeksi : ……………………………………………………………………………...
……………………………………………………………………………...
Palpasi : ……………………………………………………………………………...
……………………………………………………………………………...
4) Mata
Inspeksi : ……………………………………………………………………………..
……………………………………………………………………………..
5) Hidung
Inspeksi : ……………………………………………………………………………...
……………………………………………………………………………...
Palpasi : ……………………………………………………………………………...
……………………………………………………………………………...
6) Telinga
Inspeksi :
……………………………………………………………………………...
……………………………………………………………………………...
7) Mulut
Inspeksi :
……………………………………………………………………………...
………………………………………………………………………….......
8) Leher
Inspeksi :
……………………………………………………………………………...
……………………………………………………………………………...
Palpasi : ……………………………………………………………………………...
……………………………………………………………………………...
9) Thorax dan Paru
Inspeksi :
…………………………………………………………………………....
……………………………………………………………………………
Palpasi :
…………………………………………………………………………...
……………………………………………………………………………
Perkusi :
…………………………………………………………………………...
……………………………………………………………………………
Auskultasi : ……………………………………………………………………………
…………………………………………………………………………....
10) Payudara
Inspeksi :
....................................................................................................................
....................................................................................................................
Palpasi :
....................................................................................................................
....................................................................................................................
11) Abdomen
Inspeksi : ……………………………………………………………………………
……………………………………………………………………………
Perkusi :
……………………………………………………………………………
……………………………………………………………………………
Palpasi :
……………………………………………………………………………
……………………………………………………………………………
Auskultasi : ……………………………………………………………………………
……………………………………………………………………………
12) Genetalia
Inspeksi :
....................................................................................................................
...................................................................................................................
Palpasi :
....................................................................................................................
...................................................................................................................
13) Ektremitas
Atas
: ………………………………………………………………………………
……………………………………………………………………………….
Bawah : ………………………………………………………………………………
……………………………………………………………………………….
k.
Pemeriksaan
Penunjang
l. Terapi / Pengobatan
2. ANALISA DATA
A. Analisa Data
|
No
|
Data Penunjang
|
Masalah Keperawatan
|
Etiologi
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B. Diagnosa
Keperawatan
|
No
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Diagnosa Keperawatan
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C. Perencanaan/Intervensi
|
No
|
Tanggal
|
Diagnosa Keperawatan
|
Perencanaan/Intervensi
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No
|
Tanggal
|
Diagnosa Keperawatan
|
Perencanaan/Intervensi
|
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D. Implementasi
|
No
|
Tanggal
|
Diagnosa Keperawatan
|
Tindakan/Implementasi
|
TTD
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No
|
Tanggal
|
Diagnosa Keperawatan
|
Tindakan/Implementasi
|
TTD
|
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E.
Evaluasi
|
No
|
Tanggal
|
Diagnosa Keperawatan
|
Evaluasi
|
TTD
|
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No
|
Tanggal
|
Diagnosa Keperawatan
|
Evaluasi
|
TTD
|
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