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JURUSAN KEPERAWATAN

FORMAT PENGKAJIAN
ASUHAN KEPERAWATAN KLIEN
dengan :

Disusun oleh :
Nama :
NIM

DEPARTEMEN KESEHATAN RI
POLITEKNIK KESEHATAN MALANG
JURUSAN KEPERAWATAN MALANG

FORMAT ASUHAN KEPERAWATAN


A;

PENGKAJIAN
1; PENGUMPULAN DATA
a; Biodata
1; Nama
2; Jenis Kelamin
3; Umur
4; Status Perkawinan
5; Pekerjaan
6; Alamat
7; Tanggal MRS

:
:
:
:
:
:
:

b; Diagnosa Medis

: .............................................................................
c; Keluhan Utama
: Saat Pengkajian
..............................................................................................................................
d; Riwayat Penyakit Sekarang
:
..............................................................................................................................
..............................................................................................................................
.............................................................................................................................
.............................................................................................................................
e; Riwayat Kesehatan / Penyakit Yang Lalu

:
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

f;

Riwayat Kesehatan Keluarga :


.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

g; Pola Aktivitas Sehari


:
1; Makan dan minum

:
........................................................................................................................
........................................................................................................................
2; Pola Eliminasi
:

........................................................................................................................
........................................................................................................................
3; Pola Istirahat Dan Tidur :
.......................................................................................................................
........................................................................................................................
4; Kebersihan diri
:
........................................................................................................................
........................................................................................................................
h; Riwayat Psikososial

:
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
i; Pemeriksaan Fisik
1; Keadaan Umum
..............................................................................................................................
..............................................................................................................................
2; Tanda Vital
..............................................................................................................................
..............................................................................................................................
3; Pemeriksaan Kepala Leher
..............................................................................................................................
..............................................................................................................................
4; Pemeriksaan Integumen
..............................................................................................................................
..............................................................................................................................
5; Dada dan Thorax
..............................................................................................................................
..............................................................................................................................
6; Payudara
..............................................................................................................................
..............................................................................................................................
7; Abdomen
..............................................................................................................................
8; Genetalia
..............................................................................................................................
..............................................................................................................................
9; Ekstrimitas
..............................................................................................................................
..............................................................................................................................
i; Pemeriksaan Neurologis
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
j; Pemeriksaan Penunjang

..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
k; Terapi/Pengobatan/Penatalaksanaan
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................

Malang, .................................
Perawat
...............................................

2.

ANALISA DATA
ANALISA DATA

Nama Pasien :
Umur

No. Register :
DATA PENUNJANG

MASALAH

KEMUNGKINAN PENYEBAB

b. DIAGNOSA KEPERAWATAN
Ruang

Nama Pasien :
No. Register :

C. PERENCANAAN
1. PRIORITAS MASALAH

DAFTAR MASALAH

Ruang

Nama Pasien :
No. Register :
No. DX

TANGGAL
MUNCUL

DIAGNOSA KEPERAWATAN

TANGGAL
TERATASI

2. TUJUAN, KRITERIA STANDAR, INTERVENSI, RASIONAL

RENCANA ASUHAN KEPERAWATAN

TANDA
TANGAN

NAMA KLIEN

NO. REG

TANGGAL NO
DIAGNOSA
TUJUAN INTERVENSI RASIONAL TT
DX KEPERAWATAN KRITERIA
STANDART

RENCANA ASUHAN KEPERAWATAN

NAMA KLIEN

NO. REG

TANGGAL

TUJUAN
DIAGNOSA
KRITERIA INTERVENSI RASIONAL
KEPERAWATAN
SRANDART

NO DX

D. PELAKSANAAN

CATATAN KEPERAWATAN
Ruang

Nama Pasien :
Umur

TT

No.Registrasi :
NO

TANGGAL

NO.DX.KEP

TINDAKAN

TANDA
TANGAN

E. EVALUASI
1. EVALUASI FORMATIF
Nama
Umum:

:
No. Register : .................

No. Dx. Kep. Tanggal

Tanggal

Tanggal

Tanggal

S :

S :

S :

S :

O :

O :

O :

O :

A :

A :

A :

A :

P :

P :

P :

P :