FORMAT PENGKAJIAN

RUANG RAWAT :

TANGAAL DIRAWAT :

NO MEDREC :

TANGGAL PENGKAJIAN :

I. PENGUMPULAN DATA
A. IDENTITAS KLIEN
Nama : .................................................................................................
Umur : .................. th
Jenis Kelamin : Laki-laki / Perempuan
Pendidikan : .................................................................................................
Agama : .................................................................................................
Pekerjaan : .................................................................................................
Status Marital : .................................................................................................
Diagnosa Medis : .................................................................................................
Alamat : ...............................................................................................................................................................
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B. RIWAYAT KEPERAWATAN
1. Riwayat penyakit sekarang
a. Keluhan Utama
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b. Kronologis keluhan
1) Faktor pencetus :
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2) Timbulnya keluhan : mendadak / bertahap

3) Lamanya serangan :
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4) Upaya untuk mengatasi :

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2. Riwayat penyakit masa lalu

a. Riwayat imunisasi
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b. Riwayat alergi (obat, makanan, binatang,lingkungan)

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c. Riwayat kecelakaan
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d. Riwayat dirawat di Rumah Sakit ( kapan, alasan dirawat dan berapa lama)
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3. Riwayat Psikososial dan Spiritual

a. Adakah yang terdekat pasien
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b. Interaksi dalam keluarga

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c. Dampak penyakit pasien bagi keluarga

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d. Persepsi pasien terhadap penyakitnya

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e. Sytem nilai kepercayaan

Adakah nilai nilai agama yang bertentangan dengan kesehatannya
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Aktifitas agama yang dilakukannya selama sakit

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4. Pola kebiasaan sehari hari
a. Pola nutrisi
1) Frekuensi makan : x/hari
2) Napsu makan :
( ) baik
( ) tidak napsu makan ( alasan : mual, muntah,sariawan )
3) Jenis makanan di rumah
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4) Makanan yang tidak disukai/alergi/pantangan

( ) tidak ada
( ) ada, sebutkan :
5) Kebiasaan sebelum makan
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b. Pola eliminasi
1. BAK
Frekuensi :
Warna :
Keluhan yang berhubungan dg BAK :

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2. BAB
Frekuensi :
Warna :
Bau :
Konsistensi :
Keluhan :
Penggunaan laksatif/pencahar :
Waktu :

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c. Personal Hygiene
1) Mandi
Frekuensi :
Penggunaan sabun : ( ) Ya ( ) Tidak
2) Oral Hygiene
Frekuensi :
Penggunaan pasta gigi :( ) Ya ( ) Tidak
Waktu : ( ) Pagi ( ) sore ( ) setelah makan
3) Cuci rambut
Frekuensi :
Penggunaan shampo :( ) Ya ( ) Tidak
4) Menggunting kuku:
Frekuensi :
d. Pola istirahat / tidur
1) Lama tidur :
2) Tidur siang :( ) Ya ( ) Tidak
 3) Kebiasaan sebelum tidur/ pengantar tidur :
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4) Keluhan / masalah :
( ) sulit tidur
( ) sering / mudah terbangun
( ) merasa tidak puas setelah tidur
e. Pola aktivitas dan latihan
1) Merokok
( ) Ya ( ) Tidak
Frekuensi :
Jumlah :
Lama pemakaian :
2) Minuman keras
( ) Ya ( ) Tidak
Frekuensi :
Jumlah :
Lama pemakaian :
3) Ketergantungan obat
( ) Ya ( ) Tidak
Frekuensi :
Jumlah :
Lama pemakaian :
Alasan/keluhan :
C. PEMERIKSAAN FISIK
Tanda tanda vital
Tensi = mmHg
Nadi = x/menit
Respirasi = x/menit
Suhu = C
Kesadaran :
Keadaan umum :
1. Bentuk tubuh :
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2. Tinggi badan : .................... CM

3. Berat badan : .................... Kg
4. Bentuk muka :
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5. Mata :
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6. Telinga :
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7. Hidung :
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8. Rambut :
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9. Mulut :
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10. Dada :
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11. Abdomen :
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 12. Ekstremitas :
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13. Genitalia :
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D. DATA PENUNJANG
1. Pemeriksaan laboratorium :
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2. Radiologi :
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3. USG :
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4. Lain lain :
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E. TERAFI / PENATALAKSANAAN
II. ANALIS A DATA

NO DATA ETIOLOGI MASALAH

NO DATA ETIOLOGI MASALAH
 III. DIAGNOSA KEPERAWATAN

TANGGAL TANGGAL
TANDA
NO MASALAH DIAGNOSA KEPERAWATAN MASALAH KET
TANGAN
MUNCUL TERATASI
 TANGGAL TANGGAL
TANDA
NO MASALAH DIAGNOSA KEPERAWATAN MASALAH KET
TANGAN
MUNCUL TERATASI
IV. INTERVENSI KEPERAWATAN
N DIAGNOSA RENCANA TINDAKAN
O KEPERAWATAN TUJUAN INTERVENSI RASIONAL

N DIAGNOSA RENCANA TINDAKAN

O KEPERAWATAN TUJUAN INTERVENSI RASIONAL
 V. IMPLEMENTASI

No Tanggal Tindakan Keperawatan dan Respon Tanda Tangan

No Tanggal Tindakan Keperawatan dan Respon Tanda Tangan

VI. EVALUASI
 Diagnosa Tanda
No Tanggal Catatan Perkembangan
Keperawatan Tangan
 Diagnosa Tanda
No Tanggal Catatan Perkembangan
Keperawatan Tangan
 Rencana Tindakan
No Diagnosa Keperawatan
Tujuan Intervensi Rasional

ASUHAN KEPERAWATAN