I. IDENTITAS KLIEN
Umur :.................................................................................
Agama :.................................................................................
Alamat :.................................................................................
Pendidikan :.................................................................................
1. Keluhan utama
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2. Alasan masuk RS
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2. Riwayat Alergi
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1. Riwayat penyakit
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D. GENOGRAM
KETERANGAN
: laki-laki
O : wanita
: meninggal
: menikah
: serumah
: klien
A. Keadaan Umum
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Tempat :...........................................................................................................
Orang :...........................................................................................................
1. Kepala
Kebersihan :………………….
Kebersihan:……………
Kemampuan mendengar:……………
Lesi bibir
Radang tenggorok
Wajah : ...........................................................................................................................................
Keluhan :.............................................................................................................................................
Peningkatan JVP
Keluhan : ……………………………………………………………………………………….
Keluhan :………………………………………………………………………………………..
4. Dada
S1 “LUP” S2 “DUP” S3 S4
Keluhan : ………………………………………………………………………………………
5. Abdomen
I : Buncit Datar
Distensi
Keluhan :…………………………………………………………………………………………
Keluhan : …………………………………………………………………………………
Keluhan : ……………………………………………………………………………………
Jahitan :…………cm
Fungsi syaraf :
NI : Normal Gangguan
N IV : Normal Gangguan
N V : Normal Gangguan
N VI : Normal Gangguan
N IX : Normal Gangguan
NX : Normal Gangguan
N XI : Normal Gangguan
Keluhan : ………………………………………………………………………………………
5. Kebiasaan hidup :
Konsumsi alcohol
Konsumsi rokok
Konsumsi kopi
Olahraga
Porsi makan :
Jenis :
Porsi makan :
Jenis :
C. Pola Eliminasi
Warna :
Konsistensi :
Keluhan : …………………………………………………………………………..
Warna :
Jumlah :
Dept. Dasar Keperawatan dan Keperawatan Dasar
PSIK STIKES Kendal tahun 2009
Format Dokumentasi Asuhan Keperawatan
Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan
Keluhan : …………………………………………………………………………..
3. Keluhan :
P :
Q :
Q :
R :
S :
T :
4. Keluhan :………………………………………………………………………………….
3. Konsep diri :
a. Citra diri :
b. Identitas :
c. Peran :
d. Ideal diri :
e. Harga diri :
Lainnya :…….
3. Upaya kesehatan yang bertentangan dengan keyakinan : Ada :…………… Tdk ada
V. PEMERIKSAAN PENUNJANG
A. Pemeriksaan laboratorium
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B. Pemeriksaan Radiologi
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C. ECG
D. ……………………
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E. THERAPY MEDIS
IVFD :..............................................................................................................................................
Injeksi :..............................................................................................................................................
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………………..,…….………….2009
Mahasiswa,
NIM………………………………......
F. ANALISA DATA
1. Diagnosa Keperawatan
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Ttd
No Diagnosa Keperawatan Tujan Rencana Intervensi Rasional Dan
Nama
TTD
Tanggal & No.
IMPLEMENTASI RESPON HASIL dan
Jam Dx
Nama
J. CATATAN PERKEMBANGAN
TTD
Tanggal & No.
EVALUASI dan
Jam Dx
Nama