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ASUHAN KEPERAWATAN

A. PENGKAJIAN
1. PENGUMPULAN DATA
a. Biodata
1) Nama

2) Jenis Kelamin

3) Umur

4) Status Perkawinan

5) Pekerjaan

6) Agama

7) Pendidikan terakhir

8) Alamat

9) Tanggal MRS

b. Diagnosa Medis

c. Keluhan Utama

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d. Riwayat Penyakit Sekarang :
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e. Riwayat Kesehatan/Penyakit yang Lalu :
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f. Riwayat Kesehatan Keluarga
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g. Pola Aktivitas Sehari-hari


1) Makan dan minum
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2) Pola Eliminasi
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3) Pola Istirahat dan Tidur
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4) Kebersihan Diri
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h. Riwayat Psikososial
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i. Pemeriksaan Fisik
1) Keadaan Umum:
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2) Tanda Vital:
TD

Nadi

Suhu : .
RR

3) Pemeriksaan kepala leher:


Kepala

Mata

Hidung

Mulut

Leher

4) Pemeriksaan integument:
Inspeksi :
Palpasi :
5) Dada dan thorax
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6) Payuda
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7) Abdomen
Inspeksi :
Auskultasi:
Palpasi :
Perkusi:
8) Genetalia
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9) Ekstremitas
Kekuatan otot

edema

j. Pemeriksaan Neurologis
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k. Pemeriksaan Penunjang

l. Terapi/Pengobatan/Penatalaksanaan

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Perawat