YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

Jl. Beliang No. 110 Telp / Fax (0536) 3227707
FORMAT ASUHAN KEPERAWATAN OK
Nama Mahasiswa

: .

NIM

: .

Ruang Praktek

: .

Tanggal Praktek

: .

Tanggal & Jam Pengkajian

: .

I.

PENGKAJIAN
A.

B.

IDENTITAS PASIEN
Nama

: ..

Umur

: ..

Jenis Kelamin

: ..

Suku/Bangsa

: ..

Agama

: ..

Pekerjaan

: ..

Pendidikan

: ..

Status Perkawinan

: ..

Alamat

: ..

Tgl MRS

: ..

Diagnosa Medis

: ..

RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama /Alasan di Operasi :
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2. Riwayat Penyakit Sekarang :

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3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)
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4.

Riwayat Penyakit Keluarga

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GENOGRAM KELUARGA :

C.

PEMERIKASAAN FISIK
1. Keadaan Umum :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
2. Tanda-tanda Vital :
a. Suhu/T

: .0C Axilla Rektal Oral

b. Nadi/HR

: x/mt

c. Pernapasan/RR

: ....x/tm

d. Tekanan Darah/BP

: .....mm Hg

3. DATA PENUNJANG (RADIOLOGIS, LABORATURIUM, PENUNJANG LAINNYA)

4. PENATALAKSANAAN MEDIS (Preoperatif, Premedikasi, Post Operatif)

Palangka Raya,..
Mahasiswa

ANALISIS DATA
DATA SUBYEKTIF DAN

KEMUNGKINAN

DATA OBYEKTIF

PENYEBAB

MASALAH

PRIORITAS MASALAH

RENCANA KEPERAWATAN
Nama Pasien : ..
Ruang Rawat : ..
Diagnosa Keperawatan

Tujuan (Kriteria hasil)

Intervensi

Rasional

Diagnosa Keperawatan

Tujuan (Kriteria hasil)

Intervensi

Rasional

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/Tanggal
Jam

Implementasi

Evaluasi (SOAP)

Tanda tangan dan

Nama Perawat

Hari/Tanggal
Jam

Implementasi

Evaluasi (SOAP)

Tanda tangan dan

Nama Perawat