ASUHAN KEPERAWATAN PADA Tn/Ny.

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DENGAN GANGUAN SISTEM ………………………… : …………………..…..DI RUANG ……………
RSUD TARAKAN

Nama :
NIM :

PROGAM PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN INDONESIA MAJU
 LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN PADA Tn. ………….. DENGAN GANGUAN SISTEM ……………………….. :
……………………….. DI RUANG ………………………
RS ……………………………

Telah Disyahkan
Pada tanggal:

Mengetahui :

Pembimbing Akademik Pembimbing Klinik

(…………………………..) (………………………………)

PROGAM PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN INDONESIA MAJU
ASUHAN KEPERAWATAN PADA Tn. ………….. DENGAN GANGUAN SISTEM ……………………….. :
……………………….. DI RUANG ………………………
RS ……………………………

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 kesehatan sekarang :

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3. Riwayat Kesehatan dahulu :

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4. Riwayat Kesehatan keluarga :

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5. Genogram

6. Pemeriksaan Fisik (Per Sistim)

a. Sistem Pernapasan
Inspeksi : ……………………………………………………………………………………………….....................
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Palpasi : ……………………………………………………………………………………………….......................
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Perkusi : ………………………………………………………………………………………………......................
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Auskultasi : …………………………………………………………………………………………........................
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b. Sistem Kardiovaskuler
Inspeksi : ……………………………………………………………………………………………….....................
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Palpasi : ……………………………………………………………………………………………….......................
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Perkusi : ………………………………………………………………………………………………......................
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Auskultasi : …………………………………………………………………………………………………………..
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c. Sistem Persyarafan
NI. Olfaktorius :
NII.Optikus :
NIII.Okulomotorius :
N4.Troklearis :
NV.Trigeminus :
NVI.Abdusen :
NVII.Vacial :
NVIII.Akustikus :
NIX.Gloso Pharingeus :
NX.Vagus :
NXI. Acesoris :
NXII.Hipoglosus :

d. Sistem Perkemihan
Inspeksi : ………………………………………………………………………………………………....................
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Auskultasi : ……………………………………………………………………………………………....................
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Perkusi : ………………………………………………………………………………………………....................
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Palpasi: ………………………………………………………………………………………….............................
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e. Sistem Pencernaan
Inspeksi : ………………………………………………………………………………………………....................
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Palpasi : ………………………………………………………………………………………………....................
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Perkusi : ………………………………………………………………………………………………...................
Auskultasi : ………………………………………………………………………………………………………….
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f. Sistem Muskuloskeletal
Inspeksi : ………………………………………………………………………………………………..................
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Palpasi : ………………………………………………………………………………………………...................
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g. Sistim Endokrin
Inspeksi : ………………………………………………………………………………………………...................
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Palpasi : ……………………………………………………………………………………………….....................
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h. Sistim sensori persepsi/Pengideraan

Inspeksi : ………………………………………………………………………………………………...................
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Palpasi : ……………………………………………………………………………………………….....................
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i. Sistim integument

Inspeksi : ………………………………………………………………………………………………...................
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Palpasi : ………………………………………………………………………………………………...................
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j. Sistim imun dan hematologi

Inspeksi : ………………………………………………………………………………………………...................
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Palpasi : ……………………………………………………………………………………………….....................
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Perkusi : ………………………………………………………………………………………………....................
k. Sistem Reproduksi
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7. Pola Fungsional Kesehatan

a. Oksigenasi
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b. Cairan dan Elektrolit
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c. Nutrisi
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d. Aman dan Nyaman

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e. Eliminasi

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f. Aktivitas dan Istirahat

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g. Psikososial

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h. Komunikasi

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i. Seksual

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j. Nilai dan Keyakinan

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k. Belajar
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8. Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
Pemeriksaan Hasil Normal

b. Pemeriksaan Diagnostik
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 9. Program terapi
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D. Analisa data
No Data Etiologi Problem
E. Prioritas Diagnosa Keperawatan
1. ….
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2. …………………………………………………………………………………………………………….
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3. ……………………………………………………………………………………………………………………
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Hari/Tgl/jam No Tujuan Intervensi Rasionalisasi Ttd
diagnos Dan Kriteria Hasil (NOC) (NIC)
a (DP)
F. Intervensi Keperawatan
Hari/Tgl/jam No Tujuan Intervensi Rasionalisasi Ttd
diagnos Dan Kriteria Hasil (NOC) (NIC)
a (DP)
 G. Implementasi Keperawatan
Hari/tgl/jam No DP Implementasi Respon pasien Ttd
 H. Evaluasi
Hari/tgl/jam No DP S OAP Ttd
 Lampiran 12
FORMAT PENGGANTIAN SHIF
PRAKTEK PROFESI

Yang bertanda tangan di bawah ini:

Nama :
Jabatan :
Memberitahukan bahwa mahasiswa :
Nama :
Nim :
Stase :
tidak hadir pada hari …………tanggal ………………...sift………..dengan alasan sakit / izin / tidak ada
keterangan dan telah mengganti pada hari …………… tanggal ……..............selama ……………hari
……………..,……………………………………...
Ttd :
Perawat Atau Bidan Jaga

(……………………..)

Mengetahui :
Dosen Pembimbing KA RU / Clinical Instruktur

(……………………….) (………………………..)

Keterangan :
Sakit mengganti 1 kali (telah melampirkan surat keterangan dokter)
Izin mengganti sesuai hari yang ditinggalkan
Tidak ada keterangan mengganti 2 kali shif
 RESUME KEPERAWATAN PADA Tn. ……………
DENGAN GANGUAN SISTEM ……………………………. : ….……………………..DI RUANG
…………
RSUD TARAKAN

Nama:
NIM

PROGAM PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN INDONESIA MAJU
2018
 RESUME KEPERAWATAN

Tanggal pengkajian :
Nama Pengkaji :
Ruang :
Waktu pengkajian :
A. Identitas
1. Identitas Klien
Nama :
Tanggal lahir :
Umur :..........Th .........Bl
Jenis Kelamin :
BB :
PB/TB :
Alamat :
Agama :
Pendidikan :
Suku bangsa :
Tanggal masuk :
No. RM :
Diagnosa Medik :
2. Identitas penanggung jawab
Nama :
Umur :
Jenis kelamin :
Alamat :
Agama :
Pendidikan :
Pekerjaan :
Hubungan dengan klien:
3. Pengkajian Fokus
a. Keluhan Utama
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b. Riwayat Kesehatan
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c. Pengkajian Fungsional
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d. Px. Fisik
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e. Px. Penunjang
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 ANALISA DATA

Nama Klien : ____________________

Ruang : ____________________

TGL/JAM DATA PROBLEM ETIOLOGI

PRIORITAS DIAGNOSA KEPERAWATAN

Hari, tanggal : ___________________________

1. ………………………………………………………………………………………………
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2. ………………………………………………………………………………………………
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 RENCANA KEPERAWATAN
Nama Klien : ____________________
Ruang : ____________________

Tgl/Jam No. Tujuan dan Kriteria Hasil (NOC) Intervensi (NIC) TTD
DP
 IMPLEMENTASI KEPERAWATAN

Nama Klien : ____________________

Ruang : ____________________

No. Tgl/Jam Tindakan / Implementasi Evaluasi Formatif TTD

DP
 EVALUASI KEPERAWATAN

Nama Klien : ____________________

Ruang : ____________________

Tgl/Jam No. Evalusi Sumatif TTD

DP

S:

O:

A:

P: