Format Askep (Umum)
Format Askep (Umum)
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A. BIODATA
1. Identitas pasien
Nama : ________________________________
Umur : ________________________________
Jenis : ________________________________
Suku Bangsa : ________________________________
Agama : ________________________________
Status perkawinan : ________________________________
Pendidikan : ________________________________
Pekerjaan : ________________________________
Alamat : ________________________________
Tanggal Masuk : ________________________________
No. Register : ________________________________
Diagnosa medis : ________________________________
2. Penanggung jawab
Nama : ________________________________
Umur : ________________________________
Jenis Kelamin : ________________________________
Pendidikan : ________________________________
Pekerjaan : ________________________________
Hubungan dengan pasien : ________________________________
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B. RIWAYAT KESEHATAN
1. Keluhan Utama
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2. Riwayat penyakit sekarang
a. Alasan dirawat dirumah sakit / perjalanan penyakit
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b. Faktor pencetus
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c. Lamanya keluhan
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d. Timbulnya keluhan (bertahap/mendadak)
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e. Upaya yang dilakukan untuk mengatasinya
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3. Riwayat perawatan dan kesehatan dahulu
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4. Riwayat kesehatan keluarga
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3. Pola eliminasi
a. Eliminasi feses
1) Pola BAB (frekwensi, waktu, warna, konsistensi, penggunaan
pencahar/enema, adanya keluhan diare / obstipasi)
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2) Adakah perubahan dalam kebiasaan BAB (penggunaan alat
tertentu misal: terpasang kolostomy/ileostomy)
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5. Pola istirahat dan tidur
a. Kebiasaan tidur (waktu tidur, lama tidur dalam sehari, kebiasaan
pengantar tidur)
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c. Kemampuan kognitif (kemampuan mengingat/memory, bicara
dan memahami pesan yang diterima, pengambilan keputusan
yang bersifat sederhana)
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8. Pola reproduksi dan seksual
a. Bagaimana pemahaman pasien terhadap fungsi seksual
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2) Riwayat kehamilan (jumlah kehamilan, jumlah kelahiran,
jumlah anak)
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3) Riwayat pemeriksaan ginekologi misal pap smear
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2) Identitas ( bagaimana status dan posisi klien sebelum dirawat,
bagaimana kepuasan klien terhadap status dan posisinya,
bagaimana kepuasan klien sebagai laki-laki dan perempuan)
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3) Peran (tugas/peran apa yang diemban pasien dalam
keluarga/kelompok/masyarakat, bagaimana kemampuan klien
dalam melaksanakan peran tersebut, apakah selama dirawat
pasien mengalami perubahan dalam peran)
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4) Ideal diri (bagaiman harapan pasien terhadap
tubuh/posisi/perannya, bagaimana harapan klien terhadap
lingkungan, bagaimana harapan klien terhadap dirinya)
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5) Harga diri (bagaimana penilaian / penghargaan orang lain
terhadap dirinya, apakah klien merasa rendah diri dengan
keadaanya)
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10. Pola Mekanisme koping
Menjelaskan tentang pola koping, toleransi terhadap stress dan
support system
a. Bagaimana pasien dalam mengambil keputusan ( sendiri atau
dibantu)
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b. Yang dilakukan jika menghadapi sutu masalah (misalnya :
memecahkan masalah, mencari pertolongan / berbicara dengan
orang lain, makan, tidur, minum obat-obatan, marah, diam, dll)
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c. Bagaimana upaya klien dalam menghadapi masalahnya sekarang
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d. Menurut pasien apa yang dapat dilakukan perawat agar pasien
nyaman
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11. Pola nilai kepercayaan / keyakinan
a. Menurut pasien siapa atau apa sumber kekuatan baginya
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b. Bagaimana klien menjalankan kegiatan agama atau kepercayaan
(macam, frekwensi), apakah pasien mengalami permasalahan
berkaitan dengan aktifitasnya tersebut selama dirawat
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c. Adakah keyakinan/kebudayaan yang dianut pasien yang
bertentangan dengan kesehatan
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d. Bagaimana keyakinan pasien terhadap pengobatan yang dijalani
(adakah pertentangan dengan nilai/kebudayaan yang dianut)
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D. PENGKAJIAN FISIK
1. Keadaan umum : tampak lemah/ tampak kesakitan, tampak sesak
2. Tingkat kesadaran: _______________________________________
3. Tanda-tanda vital :
a. Suhu tubuh :
b. Tekanan darah :
c. Respirasi(jumlah, irama, kekuatan) :
d. Nadi (jumlah, irama, kekuatan) :
e. Pengkajian nyeri : Nyeri Ada/ tidak),
skala:.......
4. Pengukuran antropometri : TB, BB, Lingkar lengan atas
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5. Kepala : bentuk, adakah luka
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a. Rambut : warna, jenis, ketebalan, kebersihan
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b. Mata : kemampuan penglihatan, ukuran pupil, reaksi terhadap
cahaya, konjungtiva anemis/tidak, sklera ikterik/tidak, alat
bantu, adanya sekret
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c. Hidung : bagaimana kebersihannya, adakah septum deviasi,
adakah sekret, adakah epistaksis, adakah polip, adakah napas
cuping hidung, pemakaian oksigen
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d. Telinga : kemampuan pendengaran, adakah nyeri, adakah sekret
telinga adakah pembengkakan, penggunaan alat bantu
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e. Mulut : keadaan selaput mukosa (kelembaban, warna),
kebersihan keadaan gigi dan gusi, bau mulut, keadaan bibir
(warna, kelembaban)
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5. Leher dan tenggorok : posisi trakea, benjolan pada leher,
pemasangan alat (trakeostomy) adakah nyeri waktu menelan,
pembesaran tonsil, bagaimana keadaan vena jugularis, kemampuan
batuk efektif (mengeluarkan sputum), obstruksi jalan napas
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2. Diit yang diperoleh
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3. Therapy
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B. PENGELOMPOKAN DATA
NO TGL DATA (DS DAN DO) TTD &
NAMA
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C. ANALISA DATA
Tulis semua masalah yang muncul
DATA (DS dan DO) MASALAH (P) ETIOLOGI (E)
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D. DIAGNOSA KEPERAWATAN
Tulis sesuai prioritas
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E. PERENCANAAN
Minimal 3 diagnosa keperawatan
NO. WAKTU TUJUAN & RENCANA RASIONAL
DX (TGL/JAM) KRITERIA (NIC)
(NOC)
1.
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NO. WAKTU TUJUAN & RENCANA RASIONAL
DX (TGL/JAM) KRITERIA (NIC)
(NOC)
2.
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NO. WAKTU TUJUAN & RENCANA RASIONAL
DX (TGL/JAM) KRITERIA (NIC)
(NOC)
3.
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TINDAKAN KEPERAWATAN
NO TGL/JAM TINDAKAN RESPON PS TTD &
.DX NAMA
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NO TINDAKAN RESPON PS TTD &
.DX TGL/JAM NAMA
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NO TGL/JAM TINDAKAN RESPON PS TTD &
.DX NAMA
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F. CATATAN PERKEMBANGAN
NO WAKTU EVALUASI TTD &
DX (TGL/JA NAMA
M)
1 S:
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O:
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A:
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P:
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NO WAKTU EVALUASI TTD &
DX (TGL/JA NAMA
M)
2 S:
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________________________________
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________________________________
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O:
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________________________________
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A:
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P:
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________________________________
________________________________
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NO WAKTU EVALUASI TTD &
DX (TGL/JA NAMA
M)
3 S:
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O:
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A:
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P:
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