ASUHAN KEPERAWATAN PADA TN.

DENGAN GANGGUAN
SISTEM : …………………………………………….
DI RS INDONESIA MAJU

A. IDENTITAS KLIEN
Nama :
Umur :
Jenis kelamin :
Alamat :
Status :
Agama :
Suku :
Pendidikan :
Pekerjaan :
Tanggal masuk RS :
Tanggal pengkajian :
DX Medis :
B. IDENTITAS PENANGGUNG JAWAB
Nama :
Umur :
Jenis kelamin :
Alamat :
Pendidikan :
Pekerjaan :

C. PENGKAJIAN
1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Riwayat Penyakit dahulu :
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4. Riwayat penyakit keluarga :
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5. Riwayat pekerjaan/ kebiasaan :
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6. Riwayat Alergi
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7. Pengkajian Sistem Tubuh
a. Sistem Pernapasan
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b. Sistem Kardiovaskuler
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c. Sistem Persyarafan
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d. Sistem Perkemihan
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e. Sistem Pencernaan
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f. Sistem Muskuloskeletal
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g. Sistim Endokrin
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 h. Sistim sensori persepsi
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i. Sistim integument
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j. Sistim imun dan hematologi
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k. Sistim Reproduksi
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8. Pengkajian Fungsional

1. Oksigenasi
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2. Cairan dan Elektrolit
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3. Nutrisi
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4. Aman dan Nyaman
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5. Eliminasi
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 6. Aktivitas dan Istirahat
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7. Psikososial
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8. Komunikasi
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9. Seksual
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10. Nilai dan Keyakinan
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11. Belajar
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9. Pemeriksaan Penunjang
a. Hasil Laboratorium
Tanggal Pemeriksaan Hasil Nilai Normal Interpretasi
 b. Pemeriksaan Diagnostik
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10. Progam Terapi
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D. ANALISA DATA

Hari/Tgl/Jam Data Fokus Etiologi Problem

DIAGNOSE KEPERAWATAN
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Nama : ........................................................... Umur : ..................................................... No. Dokumen RM :
Ruang : .......................................................... Kelas : ..................................................... Tanggal :

INTERVENSI

Hari/Tgl/J Diagnosa Tujuan Dan Kriteria Hasil Intervensi TTD

am Keperawatan
Nama : ........................................................... Umur : ..................................................... No. Dokumen RM :
Ruang : .......................................................... Kelas : ..................................................... Tanggal :

IMPLEMENTASI KEPERAWATAN

Hari/Tgl/Jam Diagnosa Implementasi Respon TTD

Keperawatan
Nama : ........................................................... Umur : ..................................................... No. Dokumen RM :
Ruang : .......................................................... Kelas : ..................................................... Tanggal :

LEMBAR EVALUASI

Hari/Tgl/Jam Diagnosa Keperawatan Evaluasi TTD