FORMAT 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 : .......................................................................................

b Diagnosa Medis :

c Keluhan Utama (Saat Pengkajian)

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

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

d Riwayat Penyakit Sekarang

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

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

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

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

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

e Riwayat Kesehatan / Penyakit Yang Lalu

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

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

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

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

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

f Riwayat Kesehatan Keluarga

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

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

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

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

g Pola Aktifitas Seharihari

1 Makan dan Minum
Sebelum MRS : .....................................................................................................
...............................................................................................................................
...............................................................................................................................
Ketika MRS : ........................................................................................................
...............................................................................................................................
...............................................................................................................................

2 Pola Eliminasi

Sebelum MRS : .....................................................................................................

...............................................................................................................................
...............................................................................................................................
Ketika MRS : ........................................................................................................
...............................................................................................................................
...............................................................................................................................

3 Pola Istirahat dan Tidur

Sebelum MRS : .....................................................................................................
...............................................................................................................................
...............................................................................................................................
Ketika MRS : ........................................................................................................
...............................................................................................................................
...............................................................................................................................
4 Kebersihan Diri
Sebelum MRS : .....................................................................................................
...............................................................................................................................
Ketika MRS : ........................................................................................................
...............................................................................................................................

h Riwayat Psikososial
...............................................................................................................................
...............................................................................................................................
 ...............................................................................................................................

i Pemeriksaan Fisik
1 Keadaan Umum :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

2 Tanda Vital :
.............................................................................................................................
.............................................................................................................................

3 Pemeriksaan kepala dan leher :

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

4 Pemeriksaan integumen
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
5 Dada dan thorax
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

6 Payudara
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
 7 Abdomen
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

8 Genetalia
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

9 Ekstrimitas
.............................................................................................................................
.............................................................................................................................

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

j Pemeriksaan Neurologis
.............................................................................................................................

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

k Pemeriksaan Penujang
.............................................................................................................................

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

l Terapi/Pengobatan/Penatalaksanaan
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

Malang, ..............................
Mahasiswa
(..........................................)
2 ANALISA DATA

Nama Pasien :
Umur :
No. Register :
DATA FOKUS MASALAH KEMUNGKINAN PENYEBAB
B. DIAGNOSIS KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

1.

2.

3.
C. PERENCANAAN

1. PRIORITAS MASALAH

DAFTAR MASALAH

Ruang :
Nama Pasien :
No. Register :
No. TANGGA TANGGA TANDA
DX L L TANGA
DIAGNOSIS KEPERAWATAN
MUNCUL TERATAS N
I
 2. RENCANA ASUHAN KEPERAWATAN

RENCANA ASUHAN KEPERAWATAN

NAMA KLIEN :
NO. REG :
N
DIAGNOSA TUJUAN
TANGGAL O INTERVENSI RASIONAL TT
KEPERAWATAN KRITERIA STANDART
DX
 D. PELAKSANAAN

IMPLEMENTASI KEPERAWATAN

Ruang :
Nama Pasien :
Umur :
No. Register :
TGL PUKUL NO. IMPLEMENTASI TT
DX. KEP
 E EVALUASI

CATATAN PERKEMBANGAN

Nama :
No. Reg :

TANGGAL/PUKUL Dx. Kep DATA (SOAPIER)

 RESUME

Nama :
Umur :
No. Registrasi :
TGL DATA SUBYEKTIF & DIAGNOSIS PLANNING IMPLEMENTASI EVALUASI TT
DATA OBYEKTIF KEPERAWATAN