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

10) Tanggal pengkajian :

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 kesehata 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-tanda vital
TD

Nadi

Suhu

RR

3) Pemeriksaan kepala leher

Kepala

Mata

Hidung

Mulut

Leher

4) Pemeriksaan integumen
Inspeksi

Palpasi

5) Pemeriksaan dada dan thorax

Inspeksi

Auskultasi :

Palpasi

Perkusi

6) Pemeriksaan payudara
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7) Pemeriksaan abdomen
Inspeksi

Auskultasi :
Palpasi

Perkusi

8) Pemeriksaan genetalia
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9) Pemeriksaan ekstremitas
Kekuatan otot

j. Pemeriksaan neurologis

Edema

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k. Pemeriksaan penunjang

l. Terapi/pengobatan/penatalaksanaan

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2. ANALISIS DATA
ANALISIS DATA
Nama pasien :
Umur
:
No. Register :
DATA PENUNJANG

MASALAH

KEMUNGKINAN PENYEBAB

B. DIAGNOSA KEPERAWATAN
Nama pasien:
Ruang

No. Register :

C. PERENCANAAN
1) PRIORITAS MASALAH

2) TUJUAN, KRITERIA STANDART, INTERVENSI, RASIONAL

RENCANA ASUHAN KEPERAWATAN
Nama pasien :
No. Register :
Tgl

No.

DIAGNOSA

TUJUAN

DX

KEPERAWATAN

KRITERIA HASIL

INTERVENSI

RASIONAL

D. PELAKSANAAN
CACATAN KEPERAWATAN
Nama pasien:
Ruang

No. Register :
No.

Tgl

No. Dx

Tindakan

TT

E. EVALUASI
Nama pasien :
Ruang

No. Register :
No. Dx

Tgl :

Tgl :

Tgl :

Tgl :